AGENDA - Barnet CCG · Single CCG Helen Pettersen Simon Goodwin Ian Porter Approve 69 10:00 ... fair and transparent and offer value for money. Conflicts of interest guidance to which

Barnet Clinical Commissioning Group Governing Body Meeting Thursday, 19 September 2019 9:00 to 11:30 Committee Room 1 Hendon Town Hall The Burroughs, Hendon, London, NW4 4BG

AGENDA

Item Title Lead Action Page Time 1.0 INTRODUCTION 1.1 Welcome and Apologies

Chair Note Oral 09:00

1.2 Declarations of Interest

Chair Note 5

1.3 Declarations of Gifts and Hospitality

Chair Note Oral

1.4 Minutes of the Meeting held on 20 June 2019

Chair Approve 11

1.5 Action Log and Matters Arising

Chair Note 21

2.0 OVERVIEW AND UPDATES 2.1 Chair’s Report

Chair

Note 23 09:10

2.2 Accountable Officer’s Report

Helen Pettersen

Note

27 09:20

3.0 CHANGE PROGRAMME 3.1 Delivering the NHS Long

Term Plan in North Central London: Developing our Collective Plans

Sarah McIlwaine

Note 33 09:30

3.2 NCL CCGs – Case for Change for Merger to a Single CCG

Helen Pettersen Simon Goodwin

Ian Porter

Approve 69 10:00

4.0 ITEMS FOR APPROVAL 4.1 Approval of Decisions taken

by NCL JCC

Ian Porter Andrew Spicer

Approve 143 10:20

4.2 Revised Terms of Reference for NCL Primary Co-Commissioning Committee in Common

Ian Porter Andrew Spicer

Approve 155 10:30

1

4.3 Quality and Performance Report

Dr Murtaza Khanbhai Jenny Goodridge

Ali Malik

Note 171 10:35

4.4 Finance Report (M4) Matt Backler Simon Goodwin

Note 193 10:50

4.5 Governing Body Assurance Framework Report and Risk Appetite Update

Kay Matthews Andy Spcier

Note 199 11:00

5.0 ITEMS FOR INFORMATION AND ASSURANCE 5.1

Quality and Performance Committee – Summary of the meeting held in August 2019

Dr Murtaza Khanbhai Note 213 11:10

5.2 Clinical Commissioning, Finance and QIPP Committee – Summary of the meetings held in May, June and July 2019

Dr Barry Subel Note

5.3 Primary Care Procurement Committee Summary – a Summary of the meeting held in July 2019

Ian Bretman Note

5.4 Patient and Public Engagement Committee Summary – Summary of the meeting held in June 2019

Ian Bretman Note

5.5 NCL Primary Care Commissioning Committee – Minutes of the meeting held in April and June 2019

Paul Sinden Note 221

5.6 NCL Audit Committees in Common – Minutes of the meeting held in March 2019

Simon Goodwin Ian Porter

Note 237

6.0 QUESTIONS FROM MEMBERS OF THE PUBLIC

Questions from the public relating to items on the agenda

An opportunity to ask questions relating to agenda items at this part of the meeting.

11:15

7.0 CLOSING BUSINESS 7.1 Any other Business 11:25

2

7.2 Glossary of Acronyms Note 247

7.3 Date and venue of next meeting: 9:00, 19 December 2019 at Hendon Town Hall

7.4 Meeting Closes 11:30 Register of Interests A register of members’ interests is available for viewing by the public. The register

will be available at the meeting and is accessible online at http://www.barnetccg.nhs.uk/about-us/conflicts-of-interest.htm

3

http://www.barnetccg.nhs.uk/about-us/conflicts-of-interest.htm

4

Barnet Clinical Commissioning Group Governing Body 19 September 2019

Report Title Governing Body Register of Interests

Agenda Item 1.2

Report Summary

Governing Body members and attendees are asked to review the agenda and consider whether any of the topics might present a conflict of interest, whether those interests are already included within the Register of Interest, or need to be considered for the first time due to the specific subject matter of the agenda item. A conflict of interest would arise if decisions or recommendations made by the Committee could be perceived to advantage the individual holding the interest, their family, or their workplace or business interests. Such advantage might be financial or in another form, such as the ability to exert undue influence. Any such interests should be declared either before or during the meeting so that they can be managed appropriately. Effective handling of conflicts of interest is crucial to give confidence to patients, tax payers, healthcare providers and Parliament that CCG commissioning decisions are robust, fair and transparent and offer value for money. Conflicts of interest guidance to which all CCGs across NCL have adopted is available on the CCG website: If attendees are unsure of whether or not individual interests represent a conflict, they should be declared anyway, either at the meeting or to the Board Secretary beforehand, so that the appropriate course of action can be determined.

Recommendation The Committee is asked: To NOTE the Register of Interests which follows To DECLARE any existing or new interests in relation to items on the

present meeting’s agenda

Conflicts of Interest

The purpose of the Register is to list interests, perceived and actual, of members, that may relate to the meeting

Resource Implications

Not Applicable

Engagement

Not Applicable

Equality Impact Analysis

Not Applicable

Report History and Key Decisions

The Register of Interests is presented at each Governing Body meeting

55

http://www.barnetccg.nhs.uk/Downloads/Publications/Policies/NCL-CoI-policy-approved-27-March-2019-final.pdf

Appendices

The Governing Body Register of Interests

66

Declared Interest

(Name of the organisation and nature of business)

Fina

ncia

l In

tere

st

Non

-Fin

anci

al

Prof

essi

onal

In

tere

st

Non

-Fin

anci

al

Pers

onal

In

tere

st From

Elected Voting MembersPartners in Practice no no yes Indirect Husband is Programme Manager – Partners in Practice –

Social work training programme – Royal Borough of Kensington and Chelsea Local Authority on behalf of the Tri borough

01/05/2018 20/08/2019

NCL CCGs no no yes Indirect Accountable officer for all NCL CCGs 01/04/2017 20/08/2019

NCL CCGs no yes no Direct Chief Financer for all NCL CCGs 01/06/2017 08/08/2019

East London NHS FT no no yes Indirect wife is a senior manager 01/06/2017 08/08/2019

Everglade Medical Practice yes yes no Direct GP Partner 30/05/2017 31/05/2019

Central and North West London NHS Foundation Trust no no yes indirect Wife is a consultant pyschiatrist 31/05/2019

Primary Care Network (1W) no yes no Direct Clinical Director 01/07/2019 30/05/2019

Barnet GP Federation yes yes no Direct Practice is a member 30/05/2019

Dr Nick Dattani Elected GP Representative Millway Medical Practice yes yes no Direct GP Partner - Personal Medical Services (PMS) Practice. 14/03/2018 05/08/2019

Community ENT Clinic yes no no Direct Milway Medical Practice hosts the Community ENT Clinic for which it is paid a nominal session rate

14/03/2018 05/08/2019

Nick Dattani Medical Group Ltd Yes yes no Direct Director 14/03/2018 05/08/2019

Barnet Federated GPs yes yes no Direct Practice is a member 14/03/2018 05/08/2019

Primary Care Network 4 no yes no Direct practice is a member 01/07/2019 05/08/2019

Watling Medical Centre, Burnt Oak yes yes no Direct GP Partner 01/05/2017 09/08/2019

Barnet GP Federation yes yes no Direct member 01/05/2017 09/08/2019

Colindale BurntOak Healthcare Network –the company name of the network

yes yes no Direct Director 01/05/2017 09/08/2019

Thornhill Clinic Ltd yes Yes No Direct 25% shareholder, a primary care clinic in Luton, there is no connection to Barnet CCG or patients and no NHS activity

01/05/2017 09/08/2019

Primary Care Network 1W no yes no Direct practice is a member 01/07/2019 09/08/2019

Murtaza Khanbhai Ltd Yes Yes No Direct Director 14/08/2019 09/08/2019

Ravenscroft Medical Centre Yes Yes no Direct GP Principal 01/03/2017 15/08/2019

South Locality Barnet Practices Network Ltd no yes no Direct Member 01/05/2017 15/08/2019

Barnet GP Federation yes yes no Direct practice is a member 01/05/2017 15/08/2019

Primary Care Network 5 no yes no Direct practice is a member 01/07/2019 15/08/2019

St George's Medical Centre Yes Yes no Direct GP Partner 04/07/2003 15/08/2019

JFS Brent No yes No Direct school Governor 01/05/2017 15/08/2019

Chelsea and Westminster NHS FT no no yes Indirect husband is clinical lead for ENT 01/04/2011 15/08/2019

Charing Cross NHS Trust no no yes Indirect husband is ENT consultant 01/04/2009 15/08/2019

Primary Care Network 5 no yes no Direct Practice is a member 01/07/2019 15/08/2019

Barnet Federated GPs no yes no Direct Practice is a member 15/08/2019

Speedwell Practice. Yes Yes No Direct GP Partner 01/03/2017 12/09/2019

Speedwellness Health Ltd Yes Yes No Direct Director, this is a wholly owned subsidiary company and is dormant

01/03/2017 12/09/2019

Barnet GP Federation yes yes no Direct Member 01/03/2017 12/09/2019

NHS England’s Medical Directorate, and its Transforming Cancer Services Team

No yes no Direct Member 01/03/2017 12/09/2019

Simon Goodwin Chief Finance Officer

To Updated

Name Position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other

Type of Interest Is the interest direct or indirect?

Nature of Interest Date of Interest

Accountable Officer and NCL STP Convenor

Helen Pettersen

Dr Aashish Bansal Elected GP Representative

Dr Barry Subel Elected GP Representative

Dr Murtaza Khanbhai Elected GP Representative

Dr Charlotte Benjamin Elected GP Representative

Dr Clare Stephens Elected GP Representative

77

North Central London Cancer Commissioning Board. no yes no Direct Chair 01/03/2017 12/09/2019

National Clinical Review Group for Bowel Cancer, NHS England. no yes no Direct GP Member 01/03/2017 12/09/2019

Medical Advisory Board (to the pan cancer London Commissioning board)

No yes no Direct Member 01/11/2017 12/09/2019

All-party Parliamentary Groups for cancer. No yes no Direct By invitation she makes ad-hoc contributions 01/03/2017 12/09/2019

International Council for Standardisation in Haematology in association with the World Health Organisation

No No Yes indirect Father is a Board member 01/03/2017 12/09/2019

Bowel Cancer UK no yes no Direct Member of the Clinical Advisory Board 01/03/2017 12/09/2019

St Michael’s Grammar School, Finchley no yes no Direct Foundation Governor 01/03/2017 12/09/2019

Air Cadets 393 Squadron local group charity no no yes Direct civilian committee member 01/03/2017 12/09/2019

Primary Care Network 3 No Yes No Direct Practice is a member 01/07/2019 12/09/2019

East Barnet Health Centre Yes Yes No Direct GP Partner 01/03/2017 11/07/2019

Barnet GP Federation yes yes no Direct Practice is a member 01/03/2017 11/07/2019

Barnet Primary Care Network 2 No Yes No Direct Practice is a member 01/07/2019 11/07/2019

Local Medical Council No Yes No Direct Practice is a member 11/07/2019

Dr Louise Miller Elected GP Representative Barnet CCG no no yes indirect Spouse is Secondary Care Consultant Member of the Governing Body

10/01/2019 12/09/2019

Northwich Park Hospital no no yes indirect Spouse is Secondary Care Consultant 10/01/2019 12/09/2019

Primary Care Network 5 No Yes No Direct Practice is a member 01/07/2019 12/09/2019

Citizens Advice Bureau, Barnet no yes no Direct Chair 01/04/2017 14/08/2019

Biomedical Healthcare Ltd no no yes Indirect Son is a senior technical manager in a company offering an App for people to manage prescription requests and long-term medication programmes

01/04/2017 14/08/2019

Royal Free London no yes no Direct Member of the Council of Governors 01/04/2019 14/08/2019

Timewise Foundation CiC no no no Direct Provides occasional consultancy services for this social enterprise that helps organisations make better use of flexible working.

17/10/2018 14/08/2019

Headway East London (HEL) no yes no Direct Treasurer to HEL, which provides services to people with acquired brain injury

01/06/2018 03/09/2019

Healthcare People Management Association no yes no Direct Honorary Treasurer 01/10/2018 03/09/2019

Camden CCG no yes no Direct Lay Member for Audit and Governance 01/06/2019 03/09/2019

Our Time no yes no Direct Chair of Trustees for this charity supports children with parents with mental health issues

12/09/2019

Nursing and Midwifery Council no yes no Direct Registrant Member 12/09/2019

The Guardian no no yes Indirect Spouse is Public Services Editor 12/09/2019

Dr Jon Baker Secondary Care Doctor Phoenix GP Practice in Hendon yes no yes Indirect Spouse is a GP in Barnet 27/09/2017 06/09/2019

Dawn Wakeling London Borough of Barnet representative on the Governing Body (Executive Director, Adults and Health)

No interests declared no no no n/a nil return 13/02/2018 12/09/2019

Public Health Barnet no yes no Direct Director of Public Health Barnet, which has a statutory duty to provide a ‘core offer’ to the CCG

03/05/2018 11/09/2019

Royal Free London Group no yes no Direct Royal Free London Group Director of Public Health 01/09/2019 11/09/2019

Rory Healthwatch Representative on the Governing Body


Kay Matthews Chief Operating Officer No interests declared no no no n/a nil return 12/09/2019

Matt Backler Deputy Chief Finance Officer No interests declared no no no n/a nil return 29/09/2017 04/09/2019

Colette Wood Director, Care Closer to Home No interests declared no no no n/a nil return 27/10/2017 08/08/2019

Ruth Donaldson Joint Director of Commissioning No interests declared no no no n/a nil return 27/02/2018 03/09/2019

Sarah D'Souza Joint Director of Commissioning No interests declared no no no n/a nil return 10/01/2018 14/08/2019

Elected GP RepresentativeDr Tal Helbitz

Dr Clare Stephens Elected GP Representative

Ian Bretman Lay Member for Patient and Public Involvement

Attendees

Non-Voting Members

Dr Tamara Djuretic Public Health Representative on the Governing Body

Claire Johnston Governing Body Nurse

Dominic Tkaczyk Lay Member for Audit and Governance

88

Jenny Goodridge Director of Quality and Clinical Services Care Sub-Committee for the Joseph Rowntree Foundation (JRF) yes yes no direct Member of the Care Sub-Committee. In the unlikely event that the JRF bid for any local NHS services, I would be excluded from the procurement and decision-making processes.

01/03/2019 03/09/2019

Ali Malik Director of QIPP and Performance, Barnet CCG


Andy Simpson Board Secretary No interests declared no no no n/a nil return 03/04/2018 12/09/2019

Ian Porter NCL Director of Corporate Services No interests declared no no no n/a nil return 03/04/2018 13/08/2019

Eileen Fiori NCL Director of Acute Commissioning No interests declared no no no n/a nil return 12/10/2018 12/08/2019

Will Huxter NCL Director of Strategy No interests declared no no no n/a nil return 03/07/2018 08/08/2019

Paul Sinden NCL Director of Performance, Planning & Primary Care


Richard Dale Director of Programme Delivery, NCL STP


Andrew Spicer NCL Head of Governance and Risk No interests declared no no no n/a nil return 13/08/2019 13/08/2019

Karl Thompson NCL Senior Head of Corporate Services No interests declared no no no n/a nil return 12/10/2018 09/08/2019

99

1010

Page 1 of 9

BARNET CLINICAL COMMISSIONING GROUP GOVERNING BODY

Minutes of part one of the meeting held at 9:00 on Thursday 20 June 2019 Committee Room 1, Hendon Town Hall, The Burroughs, Hendon, London, NW4 4BG

Present: Elected Voting Members: Dr Charlotte Benjamin (Chair) Elected GP Representative (South Locality) Dr Tal Helbitz Elected GP Representative (North Locality) Dr Nick Dattani Elected GP Representative (Pan-Barnet) Dr Clare Stephens Elected GP Representative (North Locality) Dr Murtaza Khanbhai Elected GP Representative (West Locality) Dr Aashish Bansal Elected GP Representative (West Locality) Dr Louise Miller Elected GP Representative (Pan-Barnet) Appointed Voting Members: Dominic Tkaczyk Lay Member for Audit and Governance, Barnet CCG Ian Bretman Lay Member for Public and Patient Engagement, Barnet CCG Claire Johnston Nurse Member, Governing Body Helen Pettersen Accountable Officer for Barnet, Camden, Enfield, Haringey and

Islington CCGs (NCL CCGs) Simon Goodwin Chief Finance Officer, NCL CCGs Non-Voting Members: Selina Rodrigues Healthwatch Barnet Representative Dawn Wakeling Strategic Director of Adults, Communities and Health, London

Borough of Barnet Jeff Lake Public Health Barnet (for Tamara Djuretic, Director of Public

Health) In Attendance: Kay Matthews Chief Operating Officer, Barnet CCG Ruth Donaldson Director of Commissioning, Barnet CCG Jenny Goodridge Director of Quality and Clinical Services, Barnet CCG Matt Backler Director of Finance, Barnet CCG Ali Malik Director of QIPP, Planning and Performance, Barnet CCG Dan Glasgow Deputy Director of Primary Care Transformation Karl Thompson NCL Senior Head of Corporate Services Andrew Spicer NCL Head of Governance and Risk Rory Cooper Healthwatch Barnet Robyn Barker Multi-Disciplinary Nurse (Patient Story) Andrew Simpson Board Secretary, Barnet CCG (minutes) Apologies: Dr Barry Subel Elected GP Representative (South Locality) Dr Jon Baker Secondary Care Clinician, Barnet CCG Dr Tamara Djuretic Director of Public Health, Barnet Colette Wood Director of Care Closer to Home, Barnet CCG Sarah D’Souza Director of Commissioning, Barnet CCG

1111

Page 2 of 9

1. OPENING BUSINESS 1.1 Welcome and Apologies 1.1.1

The Chair welcomed members and attendees, noted the apologies which had been received and advised that the meeting was quorate.

1.2 Declarations of Interests Register 1.2.1 1.2.2

The Chair advised that the Barnet GP Federation should be added to the declarations of all GP Members of the Governing Body, and invited attendees to declare any existing or new interests in relation to agenda items. None were raised. Karl Thompson added that memberships of primary care networks would need to be included within GPs’ declarations as the networks develop.

1.3 Declarations of Gift and Hospitality 1.3.1 No new declarations of gifts or hospitality were made.

1.4 Minutes of the Meeting held on 7 March 2019 1.4.1

The Governing Body APPROVED the minutes of the meeting held on 7 March 2019 subject to the inclusion of Dr Louise Miller within the list of voting members in attendance.

1.5 Action Log 1.5.1 1.5.2 1.5.3

The following updates were provided in relation to open items on the action log, noting that a report on domestic violence was included within the meeting papers to respond to action number GB/11-18-001. GB/01-19-002 - an update on actions taken to address outpatient complaints Ruth Donaldson advised that work was ongoing to improve the process at Royal Free London (RFL) to improve the process to reschedule outpatient appointments which have been cancelled by the Trust. The matter had been discussed at the Governing Body’s Patient and Public Engagement Committee, at which it was agreed that a working group would be established with patients as members, in order to discuss the issues and potential solutions.

2. OVERVIEW AND UPDATE REPORTS 2.1 Chair’s Report 2.1.1 2.1.2

Dr Charlotte Benjamin introduced her Chair’s Report, highlighting in particular:

A recent InterGreat meeting at which system partners showed strong commitment to collaborating strategically on the development of a local integrated care system;

A CCG-hosted public engagement event as part of Dying Matters Week. The discussions about advanced care planning and choice for people in their last phases of life had encouraged more proactive conversations with patients registered within her own practice.

In relation to the NHS Long Term Plan, Rory Cooper advised that Healthwatch Barnet had collated feedback from Barnet residents through a survey and engagement events held in April and May. The findings had been submitted to NHS England (NHSE).

1212

Page 3 of 9

2.1.3

The Governing Body:

NOTED the Chair’s Report RATIFIED Chair’s Actions taken since the last meeting to:

APPROVE the terms of office of two GP Members of the Governing Body following their successful re-election;

APPROVE the decision taken by a Committee in Common on 24 April to launch a public consultation on the relocation of Moorfield’s Eye Hospital;

APPROVE the implementation of Health Information Exchange in Barnet following discussions with the Information Commissioner’s Office on information governance and patient communication matters;

APPROVE submission of the CCG’s draft 2019-20 draft budget to NHSE.

2.2 Accountable Officer’s Report 2.2.1 2.2.2 2.2.3 2.2.4

Helen Pettersen presented her Accountable Officer’s report, drawing members’ attention to a summary of the approach adopted by NCL CCGs to implement the national integrated care agenda detailed within the NHS Long Term Plan. Ms Pettersen advised that informal sessions had been held with the Governing Bodies of all five NCL CCGs to discuss the potential for a merged CCG for NCL, as well as the work required and timescales involved to consider and plan this. Discussions would also be held with partners outside of NCL. Selina Rodrigues stated that collaborative working with Healthwatch Barnet would be valuable to discussions of closer working across NCL. Kay Matthews added that new statutory multi-agency safeguarding arrangements for children in Barnet had been approved by the Governing Body’s Quality and Performance Committee at its meeting on 6 June, in line with authority delegated to it by the Governing Body at its meeting in March. The Governing Body:

NOTED the Accountable Officer’s Report; AGREED to delegate approval of new arrangements for a Barnet Child Death

Overview Panel to the Quality and Performance Committee.

2.3 Integrated Quality and Performance Report 2.3.1 2.3.2 2.3.3 2.3.4

Jenny Goodridge introduced the quarterly integrated quality and performance report, which provided members with a detailed view of providers’ performance in relation to key quality measures. Ms Goodridge advised that the report’s statement that there had been no ‘never events’ at Royal Free London (RFL) since October 2018 was correct at the time of print, but there had been a development, for which there would be a more detailed update in part two of the meeting. RFL had completed the actions contained within the remedial action plan, which had been developed in response to a contract performance notice raised by Barnet CCG following a number of Never Events in 2018. The CCG was working with the Trust to test the actions, following concern that previous learning had not been fully embedded. The number of serious incidents at RFL had increased across December 2018 and January 2019, resulting in a backlog of incidents which required investigation. The

1313

Page 4 of 9

2.3.5 2.3.6 2.3.7 2.3.8 2.3.9 2.3.10

CCG had requested that the Trust produce a process to prioritise these cases and for assurance updates on the completion of investigations. Ms Goodridge provided an update in relation to work undertaken to address concerns previously raised by Governing Body Members about the management of pathology results. As well as duplication of results, there had been incidences of abnormal results not being flagged, resulting in delayed action by GPs, and concerns had been raised about the length of time being taken for results to be reported. A working group had been established which had addressed most of the issues, and a document outlining the process to follow had been shared with relevant people. Although some concerns continued to be reported initially, the volume had decreased. Immediate safety concerns were being addressed. Communications had been issued to GPs showing abnormal ranges in order to remind GPs of the pathology levels at which they would be notified immediately by the laboratory of significantly abnormal results. The following was noted in response to questions raised:

There had been a 4% improvement in recovery rates in May for Improving Access to Psychological Therapies;

There was confidence that the commitment to completing fifteen serious incident investigations by the end of June 2019 was achievable. A team at RFL had been assigned to undertake this work;

Ali Malik provided an overview of provider performance in relation to service access, reporting the following key points:

Performance against the cancer 62-day and two-week standards for CCG-commissioned services had deteriorated in March. A quantitative faecal immunochemical test pilot introduced in April had shown early signs of a reduction in referrals, which in turn would be expected to alleviate service pressures;

There had been an improvement to the A&E four-hour standard at RFL since winter as expected, though challenges remained at Barnet Hospital;

Performance in relation to referral-to-treatment (RTT) metrics had improved since the previous quarter, though this still fell short of the national target, and was largely due to RFL data being excluded from the position due to their having ceased reporting until data quality issues could be addressed. The CCG was reviewing the Trust’s RTT improvement action plans;

Central London Community Healthcare NHS Trust achieved the RTT standard in March.

Members reviewed CCG performance against NHSE’s Improvement and Assessment Framework (IAF) designed to monitor performance against a range of quality and performance metrics. The CCG had developed its own measurement and ranking framework in order to monitor ongoing performance. There had been improvement against some metrics compared with the previous quarter (the previous quarter in 2018-29), including a 27% improvement in working with stakeholders and partners. The previous year’s overall position would be published in July 2019. It was noted that data reported for mental health out of area placements by the provider contained some errors which distorted the reported position. Once corrected, the position is expected to show an improvement for the CCG against this metric. The following was noted in response to questions and concerns raised by members:

1414

Page 5 of 9

2.3.11

The CCG is not aware of any of its other key providers experiencing the same RTT data quality issues as the Royal Free. However it was acknowledged that other providers in London and nationally had experienced similar data quality issues in the past;

There were sixteen ‘red-rated’ metrics. For some of them, this was based upon 2016-17 data, which would preclude immediate improvements. Data updates were being produced on a regular basis in order to build a more contemporaneous picture, and work was ongoing with clinical leads to develop improvement plans. Part of this work involved identifying wherever improvements could be achieved quickly;

Significant preparation was underway ahead of an imminent Care Quality Commission (CQC) inspection of Barnet, Enfield and Haringey Mental Health Trust following concerns by commissioners of the Trust’s compliance levels with mandatory training for life support and safeguarding. Additionally, the CQC had been attending BEH’s Clinical Quality Review Group meetings and was engaging with members of the public and other stakeholders.

The Governing Body NOTED the Integrated Quality and Performance Report.

2.4 CQC Report on RFL 2.4.1 2.4.2 2.4.3 2.4.4

Jenny Goodridge introduced a report which detailed the findings of a CQC inspection of RFL undertaken in December 2018 and January 2019. The result was an overall rating of ‘requires improvement’. The Trust also received ‘requires improvement’ for the individual domains of ‘safe’ and ‘responsive’ services. The CCG’s concerns in relation to this were reflected on its corporate risk register. The Trust received ‘good’ ratings for the domains of ‘caring’, ‘effective’ and ‘well-led’ services. Eleven ‘must do’ (high priority) actions had been mandated by the CQC. The Trust had developed an action plan designed to address these areas, which had been submitted to the CQC and the CCG for comment. The CCG had requested that the Trust combine the action plans it had developed across a range of areas into one overarching improvement plan. A meeting would be scheduled between RFL, the CQC and regulators to agree next steps. The following was noted in discussion of the report:

The improved executive oversight of issues at a Trust-wide level over the preceding year gave confidence in RFL’s ability to drive improvements and embed learning;

Some of the priority actions related to cultural issues and had also been identified as part of the review on ‘never events’. The cultural nature of them would preclude a rapid fix;

It would be valuable to understand how learning from providers which had been given ‘good’ CQC ratings could be used to support improvements at RFL.

The Governing Body NOTED the CQC Report on RFL.

2.5 Domestic Violence: The You Are Not Alone programme and the IRIS Project 2.5.1

Jeff Lake presented a report by Public Health on domestic violence. The report provided members with detailed statistics on domestic violence, as well as an overview of the partnership approach to responding to it and Barnet’s strategy to prevent and protect, which included the ‘You Are Not Alone’ and ‘Identification and Referral to Improve Safety’ (IRIS) programmes.

1515

Page 6 of 9

2.5.2 2.5.3

Assurance was sought in relation to lack of referrals for staff members since 2016, and that there were programmes in place to work with perpetrators of domestic violence in order to adopt a holistic approach. The Governing Body:

NOTED the report; AGREED that a follow-up communication would be circulated to members to

provide assurance in relation to work to identify the reasons for a lack of referrals from staff members, and on programmes for perpetrators of domestic violence.

3. FINANCE & GOVERNANCE 3.1 Budget Setting for 2019-20 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 3.1.6

Matt Backler presented a summary of the CCG’s 2019-20 final budget, which had been submitted to NHSE on 15 May 2019 following detailed discussion of an earlier draft (submitted to NHSE on 4 April) at meetings of the Governing Body and its Clinical Commissioning Finance and QIPP Committee (CFQ). The final version of the budget was approved for submission to NHSE by the Chair of the Governing Body, Chief Finance Officer and the Lay Member for Audit and Governance, under authority delegated to them by CFQ. Following NHSE’s review of the draft budget, the CCG was required to improve its position. As such, the final budget detailed the CCG’s plans to achieve a deficit of £6.7m deficit, a £5.0m improvement on the £11.7m deficit shown in the draft plan. This was made possible through:

The release of a planned contingency of £2.9m; The release of primary care contingency of £1.0m; and A reduction in the acute budget by a net sum of £1.0m (due to movements in

planning assumptions on the four main acute trusts following the signing of contracts).

Mr Backler stated that the reduced budget was achievable though remained challenging. Acute contracts had now been signed and with less risk due to the contract form which had been agreed. Successful delivery of the CCG’s QIPP Programme would be key in achieving the 2019-20 financial plan. It was not possible to give reliable forecasts on delivery of either the financial or QIPP plans with month-one data. Simon Goodwin added that all NCL CCGs except Islington were expected to have a deficit at the end of the current financial year. NHSE had not yet issued guidance on how the national directive for CCGs within a Sustainability and Transformation Partnership to merge would be expected to impact upon individual CCG budgets. In discussion of the budget report, members expressed concern that the CCG had been advised by regulators to release its full contingency at the beginning of the year in order to improve its budget position. The Governing Body NOTED the report on budget setting for 2019-20.

3.2 Independent Funding Requests Appeals Panel Terms of Reference 3.2.1

Andrew Spicer introduced the paper. He noted that when NHS Barnet, Enfield, Haringey and Islington CCGs agreed in November 2018 to form a joint panel to make decisions on Individual Funding Requests (IFR), it was recognised that further work

1616

Page 7 of 9

3.2.2 3.2.3 3.2.4

would be required on the IFR Appeals Panel Terms of Reference. The Terms of Reference had since been developed, incorporating strengthened governance arrangements and additional protection from judicial review. An overview of the proposed membership, purpose and remit of the IFR Appeals Panel had been undertaken. In discussion, it was clarified that:

The voting membership of the IFR Panel and the IFR Appeals Panel would be different from each other. It was agreed that this would be expressly set out in the IFR Appeals Panel Terms of Reference;

The role of the Appeals Panel would be to hear appeals from the IFR Panel. It would not reconsider the merit of the cases, but rather ensure that the IFR Panel followed proper process when making decisions. The number of urgent decisions required to be taken virtually would be very low.

The Governing Body APPROVED the proposed terms of reference for the Independent Funding Requests Appeals Panel subject to more explicit reference that the voting membership of the IFR Panel must differ from that of the IFR Appeals Panel.

3.3 NCL Joint Commissioning Committee – Revised Terms of Reference 3.3.1 3.3.2

Mr Spicer introduced a report setting out revised terms of reference for the NCL Joint Commissioning Committee (‘NCL JCC’). He noted that that a question had been raised by a member of the public on the deadline for deputations when there is a public holiday. Mr Spicer confirmed that the NCL JCC Terms of Reference would be amended to provide flexibility for public holidays and for any instances on which papers are published late. It was agreed that this change would be incorporated into the Standing Orders. The Governing Body APPROVED the revised terms of reference and Standing Orders for the NCL Joint Commissioning Committee.

3.4 Patient Story 3.4.1 3.4.2 3.4.3

Robyn Barker (Multi-Disciplinary Frailty Specialist Nurse) provided an account of an elderly recipient of care from an integrated and multi-disciplinary team (MDT) from one of Barnet’s primary care networks. Ms Barker spoke about how a previous approach of clinical interventions had been replaced by a more holistic and multi-disciplinary approach to the management of the patient’s physical and mental health in a way that was more directly responsive to his wishes, which were gauged by conducting a detailed assessment. The MDT worked in conjunction with a variety of professionals and agencies across the health and voluntary sectors to ensure that the patient’s medical and wider determinants of health were considered, which included supporting the patient with a clean living environment and medicines management. Members and attendees were encouraged by the outcomes of this integrated way of working, and noted the following:

It would be necessary to continue to give great importance to wider determinants of health when working in integrated ways to address patients’ needs holistically, particularly in light of evidence which showed that up to 90% of outcomes were affected by those wider determinants of health;

1717

Page 8 of 9

Consideration would need to be given to how the voluntary sector could be supported to deliver more integrated care work;

There would need to be consideration of the quality elements and measures of such integrated care if it were to become a more common approach.

3.5 Governing Body Assurance Framework Report 3.5.1 3.5.2 3.5.3 3.5.4 3.5.6

Kay Matthews introduced the Governing Body Assurance Framework (GBAF) Report, advising that it included all risks with ratings of 15 or over based on calculations of their likelihood and impact. The register of risks included those delegated to the NCL Joint Commissioning Committee and Primary Care Co-Commissioning Committee in Common, for which members of those committees provided ongoing scrutiny. The full GBAF register was included within the papers. Ms Matthews reported the following changes since the March 2019 report to Governing Body: Risk which had been closed:

GBAF 4: Failure to Deliver Statutory and Other Financial Requirements Set By NHS England;

GBAF 5: Failure to Deliver the QIPP and Transformation Programme; GBAF 23: Potential for increase in non-elective activity and costs at Royal Free

Hospital to negatively affect the CCG financial position. New risks:

CRR 1: Failure to Deliver 2019-20 Statutory and Other Financial Requirements Set By NHS England;

CRR2: Failure to Deliver the 2019-20 QIPP and Transformation Programme. The closing of GBAF4 and GBAF5 was in order to establish new finance and QIPP risks (CRR1 and CRR2) focused on the achievement of targets for the current financial year. GBAF23 had been closed because the risk was mitigated by the new contract form adopted.

3.6 Declaration of land at Finchley Memorial Hospital as surplus 3.6.1 3.6.2 3.6.3

Matt Backler introduced a paper which served to declare as surplus for health purposes an unused greenfield site at Finchley Memorial Site owned by Community Health Partnerships (CHP) – an NHS organisation responsible for the properties built under the private finance initiative policy. The paper highlighted that there was not a need for additional healthcare estate at this time and that the site had been unused for a number of years. On this basis the CCG recommended agreeing that this land was declared as surplus. The site was expected to be sold for development. It was noted that whilst the CCG could not stipulate the way in which it would be used, the current preferred options were for affordable housing and/or housing for key workers, which the CCG supported. The Governing Body APPROVED the declaration of the land as surplus.

4. ITEMS FOR INFORMATION AND ASSURANCE

4.1 Summaries of Committees of the Governing Body 4.1 – 4.4 The Governing Body NOTED the following summaries of its committees.

Quality and Performance Committee meeting held on 4 April 2019;

1818

Page 9 of 9

Clinical Commissioning, Finance and QIPP Committee meetings held on 28 February, 28 March and 25 April 2019;

Primary Care Procurement Committee meeting held on 11 April 2019; Public and Patient Engagement Committee meeting held on 21 March 2019.

4.5 NCL Primary Care Commissioning Committee in Common Minutes 4.5.1 The Governing Body NOTED the minutes of the NCL Primary Care Commissioning

Committee in Common Minutes meeting held on 21 February 2019.

4.6 NCL Audit Committee in Common 4.6.1 The Governing Body NOTED the minutes of the NCL Audit Committee in Common

meeting held on 16 January 2019 and 27 March 2019.

5.0 QUESTIONS FROM MEMBERS OF THE PUBLIC 5.1

The Chair noted that a number of questions had been received in advance by a visiting member of the public, Mr Richards, who confirmed at the meeting that the responses he had received answered his questions satisfactorily.

6.0 CLOSING ADMINISTRATION 6.1 Any Other Business 6.1.1

There was none.

6.2 Glossary of Terms 6.2.1 The Glossary of Terms was NOTED.

6.3 Date of next meeting: 6.3.1 19 September 2019, 9:00, Committee Room 1, Hendon Town Hall.

1919

2020

Agenda Item: 1.5

BARNET CLINICAL COMMISSIONING GROUP GOVERNING BODY SEPTEMBER 2019 ACTION LOG - PART 1

Rag Rating

Meeting Date Action No. Action Lead Deadline Update 10 January

2019 GB/01-19-002 Patient Story

RFL to be asked to provide an update on the actions taken to address outpatient complaints, and the improvements seen as a result of these. Regular progress updates are to be provided to the Governing Body.

Ruth Donaldson Sarah D’Souza

March 2019

At the June meeting Ruth Donaldson advised that work was ongoing to improve the process at Royal Free London (RFL) to improve the process to reschedule outpatient appointments which have been cancelled by the Trust. Further update required at the September meeting.

ITEMS COMPLETED AT OR SINCE THE JUNE MEETING 1 November

2018 GB/11-18-001 Healthwatch Healthy Hospitals Report –

Demographic Analysis of Domestic Violence (para. 2.4.7) Public Health to present a report on domestic violence which provides demographic analysis to identify themes and trends.

Angela Bartley (Deputy Director,

Public Health)

Tamara Djuretic (Director, Public

Health)

June 2019

A report was presented at the June meeting.

2121

Agenda Item: 1.5

2222

Barnet Clinical Commissioning Group Governing Body Meeting 19 September 2019

Report Title Chair’s Report to the Governing Body Agenda item 2.1

Report Author

Dr Charlotte Benjamin, Chair, Barnet CCG

Tel/Email [email protected]

Report Summary

The purpose of this report is to update Governing Body Members on activities of the Chair of the Governing Body since the last meeting on 20 June 2019.

Recommendation The Governing Body is asked to NOTE the Chair’s Report.

Identified Risks and Risk Management Actions

Not Applicable


Not Applicable


Not Applicable

Engagement

Not Applicable


Not Applicable


This is a standing item presented at each Governing Body Meeting

Next Steps Not Applicable

Appendices

None

2323

2424

Chair’s Report

It has been another busy three months, where we have made significant progress developing our relationships with Barnet local partners and with our neighbouring North Central London (NCL) CCGs. At the June meeting of the Governing Body I provided an update on progress in the design of local integrated care, advising that the CCG, and its system partners, had together tested a hypothesis for what an integrated care system should look like and considered next steps in the context of how we currently commission health and care services. As work picks up pace within NCL to implement the NHS Long Term Plan’s integrated care ambitions, a lot of work has taken place to establish how this will all be taken forward both within Barnet and NCL more widely. This work centralises on the three key strands of the change programme: the proposed merger of CCGs within NCL; and the development of Integrated Care Partnerships (ICP) and an Integrated Care System (ICS). Proposals on how this NHS Long Term Plan will be taken forward within NCL will form the predominant focus of this meeting, as the Governing Body is asked to make one of the most important decisions it will ever have made.

I have represented Barnet at various forums within the Borough and across NCL, to help establish what would be more beneficial for residents for us to commission at a borough and local ICP level, and what to do singularly across NCL as part of a wider ICS.

This work will be developed in conjunction with system partners and providers at a series of workshops aimed specifically at the development of ICPs and ICSs. The first of these workshops has taken place, at which a review of existing integrated care models proved invaluable in helping to focus a more detailed view of the future configuration of the local health economy.

Fundamental in enabling this transformation will be the breaking down of any barriers in order to facilitate the new relationships and ways of working between organisations. This is required in order to achieve system-wide consensus in what constitutes effective integration that works for the benefit of residents. Close engagement between commissioners, providers, CCG member practices and other partners at all stages of this transformation will be vital in order to achieve this.

All Primary Care Networks (PCNs) launched on 1 July with appointed clinical directors in place. The PCNs map over the Care Closer to Home Integrated Networks, which achieved 100% coverage of Barnet GP practices.

I believe strongly that these networks will be the vehicle for implementing the kind of integrated care we are all striving to achieve, as they will wrap services around the patient as and when they need it as part of a more personal and proactive approach to care. A workshop I chaired in July focused on the role of PCNs in facilitating social prescribing to enable frontline healthcare professionals to assist patients with opportunities to create solutions to their difficulties, factoring in the wider social, economic and environmental determinants of health. I look forward to the next steps in driving forward this vision of the NHS.

Dr Charlotte Benjamin Chair of the Governing Body

Barnet CCG

2525

2626


Report Title Accountable Officer’s Report

Agenda Item 2.2

Lead Director / Manager

Helen Pettersen Accountable Officer, NCL CCGs


GB Member Sponsor

Not applicable

Report Author

Helen Pettersen, Accountable Officer for Barnet, Camden, Enfield, Haringey and Islington CCGs & NCL STP Convenor


Report Summary

The Accountable Officer’s report highlights key issues for the Governing Body’s consideration that are not covered elsewhere on the agenda.

Recommendation The Governing Body is requested to note the contents of the report.


Where applicable any risks are identified within the report.


There are no conflicts of interest arising from this report.


There are no direct resource implications, although areas described has resource implications for the CCG.

Engagement

Engagement activities are highlighted as appropriate.


There are no equality impacts arising from this report.


This report is a standing item on the Governing Body agenda.

Next Steps None Appendices

None

2727

mailto:[email protected]


2828

Accountable Officer Report June to September 2019

Introduction

This report focuses on the key activities that the senior team and I have been involved in since the last Governing Body meeting and a summary of the work progressed.

1.0 European Union EXIT update 1.1 Further to the preparatory work undertaken in the spring, the NCL CCGs have continued to

work with NHS England (NHSE) and Improvement to ensure our organisations and the providers we commission remain fully prepared in the event of the United Kingdom leaving the European Union on a ‘no-deal’ basis. An assurance exercise will be undertaken at the end of August to ensure there is a key team in place in each organisation to oversee respective EU Exit preparations.

1.2 The CCGs’ resources remain in place to manage the readiness, assurance and

communications work required for EU Exit – and we await confirmation from NHSE on the date from which the full preparatory processes will restart. The CCG SRO for EU Exit will again be required to liaise with both CCGs and Trusts across North Central London.

1.3 An EU Exit workshop for the London-region has been organised for 19 September to provide

an update on the national preparations and requirements, and to understand and test the joint working arrangements and responsibilities that will be put in place.

1.4 Further updates will be provided as required to Governing Body members in the lead-up to

31st October 2.0 Health Information Exchange 2.1 The Health Information Exchange (HIE) went live in Barnet and Royal Free London (RFL) on

2 July 2019. Systems usage has been very good with no major reported issues since then. The first surgery has six GPs (two part time) and 6,900 patients, and following the duty of transparency patient information they had only 11 patients opt-out of the joined-up record. Feedback from clinicians has been positive and they were able to outline specific benefits such as time saving; reduced stress for the GP; enabling better decisions; saving unnecessary appointments and phone calls; and reduced delay, waiting and anxiety for the patient.

2.2 A plan is now being developed to roll-out to all GP practices in Barnet by around the end of

September, and a draft plan is under review for the roll-out across all partners over the next year. We are in the latter stages of testing with University College London Hospital (UCLH) which will be followed by an HIE roll-out in Islington. We have secured Health System Led Investment funding and engagement to connect Barnet, Enfield and Haringey Mental Health Trust (BEHMHT), Camden and Islington NHS Foundation Trust (CIFT) and NORT Middlesex University Hospital (NMUH), as well as strong engagement with all providers.

3.0 Primary Care Networks 3.1 NCL commissioning leads are working closely to implement the new GP Contract

Framework. The opportunity to use the Primary Care Network direct enhanced services to build integrated frontline delivery for enhanced and community-based services, with a positive impact on ‘core’ general practice delivery, is clear.

2929

3.2 Since my June Accountable Officer’s Report, all mainstream primary care practices in NCL have been confirmed in 30 primary care networks. Thirty-nine clinical directors have been appointed to lead the PCNs. PCN proposals were formally approved at the June Primary Care Committee in Common, where the excellent progress and partnership working across NCL were noted.

3.3 At the time of writing, discussions continue with NHSE and NHS Improvement to make

arrangements for two specialist primary care services. These are Camden Health Improvement Practice, most of whose patients are homeless and/or chaotic and many of whom have substance misuse problems, and the Special Allocations Service, which registers violent patients.

3.4 PCNs are very new and at different levels of maturity, depending on how well-established

the working relationships are between member practices and with other partners. Some have been collaborating on the same basis for some time, whereas other partnerships are much newer.

3.5 Thirty nine clinical directors have been confirmed. It will be critical for clinical directors and

other key partners to be involved in determining their support requirements in order to ensure the success of PCNs. We are supporting the clinical directors and PCNs to determine requirements for new (five-year recurrent) development funding. Clinical directors have started to meet in individual boroughs, and will be coming together across NCL in early September in order to discuss their support requirements.

CCG No.

PCNs

Barnet 7

Camden 7

Enfield 4

Haringey 8

Islington 4

4.0 Medium Term Financial Strategy 4.1 An oral update will be provided to ensure members are provided with the most up-to-date

information. 5.0 Provider Contracts update 5.1 The Royal Free London contract has been signed. 5.2 For UCLH, in order for the Trust to complete a signed contract they are pursuing the North

East London Sustainability and Transformation Partnership in order to increase the value of their block contracts. This is a discussion for the Chief Finance Officers between the NCL CCGs and the Trust to have, and is expected to be concluded once executives return from leave. The contractual arrangements for NCL have been agreed.

3030

6.0 Adult Elective Orthopaedic Services Review

6.1 The Adult Elective Orthopaedic Services Review continues to progress well. In May 2019, the Joint Commissioning Committee of the five NCL CCGs approved the clinical delivery model and options appraisal process, and NHS providers of orthopaedic care in north central London were asked to submit options for consideration that could meet the specifications of the agreed model of care.

6.2 In July 2019, an options appraisal process was held in order to consider the options put

forward. The panel included local commissioners and GPs as well as equal representation from patients and residents. The purpose was to assess submissions against the status quo, using a scoring system developed through a collaborative process.

6.3 An update will be provided at the Joint Health Overview and Scrutiny Committee later in

September, and NHSE assurance of the proposals will take place over autumn. The programme is on track for there to be a pre-consultation business case submitted for clinical commissioner approval in mid-November, and to ask for formal approval to go to public consultation on proposed changes to the model of care later in November.

7.0 Developing an Integrated Care Partnership (ICP) in Barnet

7.1 Following the direction outlined in the Long Term Plan (LTP) we have started work on the development of an Integrated Care Partnership (ICP) in Barnet which brings together our local commissioners and providers in Barnet. This new way of working will allow us to achieve better health and care outcomes for our residents and will use good integrated data to drive decision making. The Barnet ICP will also link into North Central London’s Integrated Care System (ICS) to allow for wider system input where required.

7.2 Over the course of this summer, we held a number of workshops with our local partners (London Borough of Barnet, Royal Free London, Central London Community Healthcare, Barnet, Enfield and Haringey Mental Health Trust and Barnet Federated GPs) where we started developing the foundations for an ICP. This included shaping the process for developing an outcomes framework, proposing interim governance arrangements and establishing the programme and key work-streams to further develop the partnership over the coming months.

7.3 The national ambition is to form a mature Integrated Care Partnership by April 2021, we will be developing a roadmap over the coming weeks to plan how to deliver this ambition.

8.0 Mental Health – Improving Access to Psychological Therapies

8.1 Barnet CCCG has implemented a programme of work to improve the performance for Improved Access to Psychological Therapies (IAPT). In February 2019, the CCG approved a business case to invest significantly into IAPT services, bringing the total annual investment in this service up to £3.44m. This has enabled the deployment of additional resources into the core IAPT contract with Barnet, Enfield and Haringey Mental Health Trust, which along with developments in services provided by Barnet Refugee Service and Barnet Mind, has resulted in improvements to both access and recovery rates, as well as reductions in 6-week and 18-week waiting times. Barnet is now meeting both access and recovery rate targets as well as the 6-week waiting time target based on local data. The CCG anticipates further improvements in service performance as the full impact of improvement plan is realised. This is a significant achievement given previous under-performance in this area.

3131

9.0 Children and Young People

9.1 In June 2019, Barnet CCG was granted Trailblazer status following a bid to NHSE to pilot the ambitions of the Children and Young People’s Mental Health Green Paper. The bid brings £800k per year (for three years) into the borough in order to fund mental health support in schools for children and young people with mild or moderate mental health needs. Barnet’s Trailblazer programme will focus on the west locality alongside the council’s locality hub, targeted at the increased levels of need identified in this area and will share learning across the borough. There will be two mental health support teams covering 33 education settings (including Barnet and Southgate College). The mental health support teams will be launched in January 2020.

10.0 Urgent Care 10.1 One of the key focuses for the Urgent and Emergency Care Team this year is to take forward

the national priority to simplify access arrangements for urgent care services. We know from engaging with Barnet patients and other stakeholders that there is some uncertainty over the range and duplication of urgent care services that are available within the Borough.

10.2 On this basis, we have been working with the Royal Free Hospital and Chase Farm to achieve

Urgent Treatment Centre (UTC) designation by September and December 2019 respectively. The team are also supporting Barnet Hospital with Section 106 funding to develop options to provide the additional space it requires within its Emergency Department to enable the hospital to become an UTC. NHSE has agreed to a deferral of UTC status at Barnet Hospital this year, subject to an approved system plan. Once designated, all hospital sites will work to a nationally-agreed service specification which ensures a common service offer for all patients.

10.3 We are also considering the future of walk-in services in line with national guidance. Initial

discussions have started with Central London Community Health Services (CLCH) about the renaming of Edgware and Finchley Memorial Hospital Walk-in Centres in line with national guidance, which also provides the opportunity to align current walk-in provision with the development of Primary Care Networks and extended general practice hours.

10.4 The contract for the provision of the Walk-in Service at Cricklewood GP Health Centre comes

to an end on 31 March 2020. Since the service began there have been changes to urgent care, more recently as part of the NHS Long Term Plan which focuses on investment into Primary Care Networks and prevention as well as local investment in 48,000 extra GP appointments in the evenings and at weekends; and also in changing patterns of walk-in activity. Therefore, between 12 August and the 4 November 2019, Barnet CCG is seeking the views of patients and stakeholders on a proposal to close the walk-in service at Cricklewood. Fuller details of the proposal and the other services are available for patients in that area are on the CCG’s website.

Helen Pettersen Accountable Officer 12 September 2019

3232

Barnet Clinical Commissioning Group Governing Body Meeting 19 September 2019 Report Title Delivering the NHS

Long Term Plan in North Central London: Developing our collective plans

Date of report

2 September 2019

Agenda Item

3.1


Will Huxter Director of Strategy, NCL CCGs


GB Member Sponsor

Helen Pettersen Accountable Officer

Report Author

Richard Dale Director of Programme Delivery


Name of Authorising Finance Lead

Simon Goodwin Chief Finance Officer, NCL CCGs

Summary of Financial Implications This paper sets out progress on the development of long term strategic plans which will have some implications for our financial plans, but these are yet to be quantified.

Report Summary

Earlier this year, across NCL, health and care system partners took part in a series of “Inter-great” events. These resulted in a consensus on the need to work together in new ways, building on the close working of our local NHS, councils and residents, to focus on delivering patient-centred care closer to home, based on individuals’ whole needs. The NHS Long Term Plan, published in January 2019, aligns closely with this direction of travel and current system transformation programmes. Developing a collective response to this provides an opportunity for us to work with partners to begin to design health services around residents’ needs, rather than organisations. These plans are currently a work in progress, and we now require the engagement and involvement of all local partners, stakeholders and residents over the next few months. In this time, they will also be cross-referenced, financially costed and refined for final agreement in November. This paper summarises the requirements of the NHS Long Term Plan, the high level approach being taken to developing collective plans and shares summaries of key areas for discussion.

Recommendation The Governing Body is asked to: NOTE the alignment to current plans and direction of travel COMMENT on the key questions posed on slide 15 SUPPORT the review of draft sections.

3333




There is a need to engage with a wide range of partners and develop a shared coherent set of plans. As a result, a structured approach is set out in the document with draft plans being shared early on in the process. Work is ongoing to map interdependencies across the plans and ensure financial reconciliation takes place and this aligns with the development of the medium term financial strategy locally. This will be undertaken over the next two months ahead of endorsing the plan in November 2019.


Not applicable.


There are no direct resource implications for this paper, as it is not a project proposal for additional internal resourcing, nor is it assuming additional external resourcing. Work on the planning process is being taken forward as part of the change programme management office.

Engagement

Engaging residents in the development of these plans will lead to better plans, more tailored to our local communities’ needs. We are working with Healthwatch as partners in engaging and involving local people in different ways as the plans develop. For the first phase (April to June): The five Healthwatch organisations across NCL were commissioned to undertake a range of engagement activities with residents, including a survey and series of focus groups. Headline areas coming out of this engagement include: access to services, patients being involved in decision-making, use of technology and access to information for residents. Phase two (July to September): includes further engagement across NCL and at a local level to engage with residents on these specific issues in more detail, as well as a detailed review of existing engagement work for gaps to understand where further conversations are needed. This will also include targeted engagement with specific seldom heard groups in each borough. Phase three (September to November): will be further engagement on our overall Long Term Plan and the London vision ahead of the full submission of our plan in November 2019.


No Equality Impact Assessment is planned or has been undertaken as part of the process for developing the Long Term Plan response itself. Once the plan is agreed it may be necessary to undertake EIA reviews for specific elements before they are implemented, where they mark a departure from current policies or approaches. This would be carried out in line with the current EIA approach.


Not applicable.

Next Steps Following review and feedback from Governing Bodies and partners, the plans will be shared with Governing Body members in November for endorsement.

Appendices

None.

3434

Delivering the NHS Long Term Plan in North Central London: Developing our collective plans

Will Huxter, Director of Strategy NCL CCGs

September 2019

3535

Contents:

2

Section Slide

Purpose of paper 3

Alignment with existing work 4

Process for developing collective plans 5

Long Term Plan Implementation Framework 6

Alignment to the Medium Term Financial Strategy 7

Working with Local Authorities 8

Engaging with our residents on the plan 9

Approach to drafting sections 10

Requirements of section for consideration by CCG GBs 14

Key questions for consideration by CCG GBs 15

Appendices:

Appendix 1: Summary of sections for discussion and notes on drafts 15

Appendix 2: Fair shares and Targeted money 27-19

Appendices 3: Plan for engagement with residents 313636

Context and purpose of paper:

3

Building on local work with partners through the STP programmes, it is clear there is a collective commitment to deliver changes that will improve the health and wellbeing of residents living in Barnet, Camden, Enfield, Haringey and Islington (‘North Central London’).

Earlier this year, across NCL, health and care system partners took part in a series of “Inter-great” events. These resulted in a consensus on the need to work together in news ways, build on the close working of our local NHS and councils, with residents, to focus on delivering patient-centred care closer to home, based on individuals’ whole needs.

The NHS Long Term Plan, published in January 2019, aligns closely with this direction of travel and current system transformation programmes. Developing a collective response to this provides an opportunity for us to work with partners to begin to design health services around residents needs, rather than organisations.

These plans are currently a work in progress, and we now require the engagement and involvement of all local partners, stakeholder and residents over the next few months. In this time, they will also be cross referenced, finically costed and refined for final agreement in November.

This paper summarises the requirements of the NHS Long Term plan, the high level approach being taken to developing collective plans and shares summaries of key areas for discussion.

The board is asked to: • Note the alignment to current plans and direction of travel• Comment on the key questions posed on slide 15• Support the review of draft sections

3737

There a chance to build on existing, ongoing work

4

Following the Inter-great events held across North Central London, work has been progressing with partners to develop new ways of working with the aim of having the greatest positive impact for the health and lives of North Central London residents.

This work is developing collective plans for and integrated care system, which would a move to planning services based on populations and individuals rather than institutions to maximise the impact we can have. It will support the reduction of health inequalities across North Central London through working to support borough based integration of services to increase the focus on residents, communities and prevention.

This direction of travel is closely aligned to that set out in the NHS Long Term Plan and means as a system, we are well placed to use this opportunity to refresh plans in areas that may need strengthening or additional focus.

Following a review of the Long Term Plan requirements, it is clear that many of the ambitions and clinical priorities set out are already being progressed or are a logical next step for our current partnership programmes of work. For example:

• Developing integrated networks based around 30-50k population through our Health and Care Close to Home programme

• Simplification of UEC system across NCL • Radical transformation of planned care and outpatients

In addition, to this, the LTP’s strong focus on workforce and digital as drivers for change is reflected by the dedicated North Central programmes established locally to deliver change in these areas.

We want to work with partners to refresh plans to take account of the latest context and support the tangible changes required across the health system as we move to integrated care. 38

38

In line with principles:

Clinically-led Locally owned involves realistic workforce

planning, Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards,

Is phased - based on local need.



















Process for developing our collective plans

5

Existing STP and Org plans

Key themes from resident engagement

Local population

health profile

Requirements from LTP Plan

Critical system inputs:

Clinically-led Locally owned Realistic workforce

planning Financially balanced and


commitments and national access standards

Phased - based on local need

Reducing health inequalities

Focussed on prevention Builds on existing work and

programmes and engages with Local Authorities

Drives innovation

Outputs of “Inter-great”

events

Plan sections drafted based on LTP implementation framework in line with principles:

Priority areas from

benchmarking

Drafted by authors, reviewed by clinical leads SROs and review groups (see slide 13)

NCL Delivery of NHS Long Term Plan

• Priority areas • Risks • Alignment with

organisational plans

Coordinated engagement with partners boards and resident on: North London

Partners

Improving health and wellbeing in NCL

Final plan for submission

• Interdependencies • Alignment with activity

and finance

Work to cross referencing sections for:

July and August Sept and October November

London Vision Drafts sections shared on websites for review by staff, partners and residents

3939

Long Term Plan Implementation Framework: summary

The LTP Implementation Framework (LTPIF) sets out the approach health systems are asked to take to create their plans. It included further details and information to help local system leaders refine their planning and prioritisation and detail about where additional funding will be made available to support specific commitments. It sets out the requirements in the sections listed below:

Seven sections on service changes. Two are national ‘fundamental service changes’ delivered in line with national timetables andtrajectories:

• Transformed ‘out-of-hospital care’ and fully integrated community-based care• Reducing pressure on emergency hospital services• Giving people more control over their own health and more personalised care• Digitally-enabling primary care and outpatient care• Better care for major health conditions: Improving cancer outcomes• Better care for major health conditions: Improving mental health services• Better care for major health conditions: Shorter waits for planned care• Increasing the focus on population health

Five section on the themes below. With Local freedom to set priorities / agree pace of delivery based on need; all LTP commitments must be delivered by the end of the five-years:

• More NHS action on prevention• Delivering Further progress on care quality and outcomes• Giving NHS staff the backing they need• Delivering digitally-enabled care across the NHS• Using taxpayers’ investment to maximum effect

https://www.england.nhs.uk/wp-content/uploads/2019/06/NHS-LTP-Implementation-Framework.pdf

64040

https://www.england.nhs.uk/wp-content/uploads/2019/06/NHS-LTP-Implementation-Framework.pdf

Our plans must support the delivery of the Medium Term Financial Strategy currently being developed

The NCL Health system has an underlying deficit of £200m per year. Work is underway to develop a medium term financial plan which will outline the work needed to support the financial sustainability of the health service, with a plan across multiple years to reduce and remove costs out of the system through a set of collective actions across NHS partners.

The financial principles will need to underpin the deliver of the MTFS, which is plan is still in development but has the following emerging themes:

• Focus on organisational recovery plans in light of the constrained income environment • Reduce demand and activity growth particularly non elective • Limit acute trust income growth to less than 2% from 2020/21 - 2023/24 • Implementation of new models of care that support the three core themes above

These themes will need to be reflected in the NCL Long Term plan response.

74141

Working with Local Authorities to develop plans

Working collectively with local authorities is critical to the delivery of changes that will improve the health and wellbeing of residents across North Central London.

To support us in developing these plans, we have worked with local authorities in the early stages of developing draft sections. We have done this through:

• Local authorities representatives have been involved in early system review groups to comment on and improve the draft sections

• We have had a dedicated Public health leads for all sections • Some of the section SROs are Local Authority senior leaders

In addition to this, over the next months, we will be working with local authority colleagues to review the drafts and develop the next iteration of these plans. We will do this through:

• Cross referencing the drafts against key themes of local authority plans strategic plans. • Review of the working drafts by senior Local Authority colleagues. • Review of sections by new borough partnerships, of which local authorities are a key member.

84242

We are already engaging with our residents on plans

Engaging residents in the development of these plans will lead to better plans, more tailored to our local communities needs. We are working with HealthWatch as partners in engaging and involving local people in different ways as the plans develop.

For the first phase (April to June): The five Healthwatch organisations across NCL were commissioned to undertake a range of engagement activities with residents, including a survey and series of focus groups. Headline areas coming out of this engagement include: access to services, patients being involved in decision-making, use of technology and access to information for residents (please see next slide for these).

Phase two (July to September): includes further engagement across NCL and at a local level to engage with residents on these specific issues in more detail as well as a detailed review of existing engagement work for gaps to understand where further conversations are needed. This will also include targeted engagement with specific seldom heard in each borough.

Phase three (September to November): will be further engagement on our overall Long Term Plan and the London vision ahead of the full submission of our plan in November 2019.

94343

The following themes from resident engagement will be used to guide the development of our plans:

From the HealthWatch surveys and focus group north central London residents told us about their priorities which we will include as themes throughout the sections of our plans:

• Increased access to services• Importance of involving patients in discussions and decisions about their care• Availability of clear and accessible information for patients, including easy read

versions and access to interpreters • Patients provided with the knowledge to keep themselves well and promote wellbeing• Integrated personalised care• Use of technology both to increase access to services and to health information• Better joint working between health and social care• Focus on prevention and early interventions• Everyone gets the same care, regardless of where they live

104444

Approach to drafting sections: chapter authors, SROs and system review groups

To ensure local plans respond to the requirements of the LTP implementation framework, we are drafting sections to cover each of the sections of the framework. To support a system approach to these, we have identified an senior responsible officer, clinical care lead, author and a system review group for each one. In addition, we have also nominated a public health lead to support the drafting of these.

The outline of these roles is listed below and the individuals responsible for each section are detailed on the following slide.

Section SRO: A nominated senior lead responsible for ensuring the completion of the content for the section and the appropriate level of engagement as required across organisations. They are responsible for ensuring a system response, rather than an organisational one.

Clinical/Care Lead(s): A nominated clinical or care lead who can provide professional input into the clinical and care professional elements of the plan. They are responsible for ensuring the clinical and care models align with the direction of travel and the needs of local populations.

System Review group: This is the current system group – or specifically nominated group that contributes, develops and reviews the section. It does not have final sign off, so does not need to be representative of all organisations but its member should be confident that engagement has happened with the key organisations as required and the section aligns with the systems direction of travel.

Section author: This is the management lead nominated to draft the section based on the guidance from the change team. They will liaise with SROs, clinical leads and the review groups to draft the proposed content for the section. They will work with those identified by the review group to engage and test the sections ahead of submitting the section to the change programme team.

114545

12

Theme SRO Clinical Lead(s) System review group Author Public Health Lead

Section 2 Delivering A New Service Model For The 21st Century: Themes And Leadership

Fully integrated community-based health care Tony Hoolaghan Dr Katie ColemanNominees from Health and Care Close to Home Board

Sarah McIlwaine Will Maimaris

Reducing pressure on emergency hospital services Sarah Mansuralli Dr Chris Streather, Dr Shakil Alam Nominees from STP UEC board Alex Faulkes Will Maimaris

Giving people more control over their own health and more personalised care

Kay Mathews TBC NCL CCG SMTShelia O’shea and Sarah D'Souza

Lilly Barnett Seher KayikciSue Hogarth

Digitally-enabling primary care and outpatient care John-Jo CampbellDrZuhaib Keekeebhai, Dr Cathy Kelly

STP Digital Board, STP planned care steering group

Martyn Smith Sarah Dougan

Improving cancer outcomes Paul Sinden Dr Clare Stephens Cancer Alliance Board Naser TarubiMary Orhewere, Aparna Keegan

Improving mental health outcomesSarah Mansuralli and Paul Jenkins

Dr Alex Warner, Dr Jonathan Bindman, Dr Vincent Kirchner

STP Mental Health Board Chris Dzikiti Tamara Djuretic

Shorter waits for planned care Paul Sinden Dr Dee Hora, Dr John ConnolleySTP Planned Care Steering Group and NCL Performance meeting

Edmund Nkrumah and Donal Markey

Glenn Stewart

Section 3 Increasing The Focus On Population Health

Moving to integrated care systems everywhere Will Huxter Dr Jo Sauvage, Dr Chris Streather NCL ICS design group Richard Dale Tamara Djuretic

Section 4 More NHS Action On Prevention

Focus on prevention Julie BilletDirectors Of Public Health/Public Health Consultants

Directors of public health Dr Hannah Logan -

Section 5 Delivering Further Progress On Care Quality And Outcomes

A strong start in life for children and young people Charlotte Pomery Dr Oliver Anglin STP Children’s Board Sam RostomSusan Otiti, Duduzile Sher-arami

Learning difficulties and autism Paul Sinden TBC NCL CCG SMT Kath McClinton

Better for major health conditions – Cardiovascular, Stroke, Diabetes, Respiratory

Will Huxter Dr Will Maimaris, Dr Julie Billet NCL CVD steering group, NCL Diabetes Group, NCL Respiritory group

Richard DaleWill Maimaris, Stuart Lines,Julie Billett

Research and innovation to drive future outcomes improvement

London wide section

Genomics London wide section

Volunteering Will Huxter Directors of nursing TBC Richard Dale -

Wider Social Impact and move to Population Health Will Huxter TBC TBC TBC Sarah Dougan

Section 6 Giving NHS Staff The Backing They Need

Feeding Back In Line With The Themes from the interim NHS People Plan

Siobhan Harrington Dr Jo SauvageSTP Workforce Steering Group and NCL Local Workforce Action Board

Sarah Young Tamara Djuretic

Section 7 Delivering Digitally-Enabled Care Across The NHS

Increase the use of digital tools to transform how outpatient services are offered and provide more options for virtual outpatient appointments

John-Jo CampbellDr Zuhaib Keekeebhai, Dr Cathy Kelly

STP Digital boardMartyn Smith and Hasib Aftab

Sarah Dougan

Section 8 Using Taxpayers’ Investment To Maximum Effect

Financial & Planning Assumptions, Improving Productivity and Reducing Variation

Simon Goodwin TBC STP Directors of Finance Gary Sired -4646

Key sections for discussion today:

13

The sections outlined below, have been highlighted for more detailed discussion at CCG Governing Bodies. This is because these areas: provide the opportunity to be more ambitious in rolling out best practice across NCL; potentially allow us to accessing additional funding; and will be critical in supporting the shift to health and care closer to home. Slides 19-26 summarise the draft sections of the plan with the requirements for these, listed below:

Developing a service model for the 21st century priorities: (See slide 18) • Developing Primary Care Networks (PCNs) as organisations, and building workforce and digital capacity to integrate services.• Introducing KPIs in community provider contracts to ensure consistency in implementing community health crisis response within 2 hours (from

20/21) and reablement care within 2 days (by 2023), building on existing good practice in some boroughs. • Strengthening anticipatory care with integrated services across health and care providers, building on effective models of practice of a number

of patient cohorts.• Implementing the enhanced health in care homes model to ensure consistency in service delivery by 23/24.

A focus on prevention: (See slide 21) • There is variation in local authority and health services for smoking, alcohol and obesity support, both in community and secondary care

settings. There is an opportunity to spread best practice across boroughs, and to bid for additional funding nationally to pilot new approaches before national rollout.

• We are continuing to build on wider system work on air pollution, AMR and targeting the obesogenic environment.

Improving outcomes in Mental health (see slide 23) • The plan build on the ambitions agreed at the NCL Expert by Experience programmes board, and the strategic priorities underpin delivery

against those, and align with the LTP priorities.• Work continues to progress with the provider development collaboratives (including a bid to NHSE re: delegating specialised commissioning

budgets), as well as work to stabilise and expand mental health community teams, particularly through expanding the workforce and implementing a new digital system

• Additional funding for mental health will be invested to expand access for services, including for CYP, perinatal and crisis care.• We have already been successful in securing pilot funding for some service areas and will continue to engage with NHSEI to make the case for

further funding in NCL to support local priorities in those areas.

4747

Key questions for discussion today:

14

How we increase pace of change and rollout of best practice to ensure consistency across NCL in the development of PCNs and community services?

Are we happy to support bids for additional national funding and addressing variation across NCL with regards to prevention?

How do we best ensure increased investment aligned to the mental health investment standard supports the development of community services? Are we happy to support further bids for national funding?

4848

Next steps and ask of Governing body members

15

Stage Who Date

Discussion on key areas • CCG GBs 10-18 September 2019

Review of working drafts,shared on website of sections and feedback to section owners

• All partners 4 October 2019

Feedback received from partners and via resident engagement

• CCG Comms teams • Healthwatch• Partner resident

groups

4 October 2019

Review and endorsement of collated plan

• CCG GBs• NHS Trust boards • Borough Partnerships • HWBBs

November 2019

4949

16

Appendix 1: Summary of plans and links to working drafts

5050

Notes on drafts

The next slides summarise some of the sections in development – to support discussion at CCG Governing Bodies in September. In addition, we are making all of the full working drafts available on our website for review and comment. These can be found here: http://www.northlondonpartners.org.uk/ourplan/the-nhs-long-term-plan.htm

Please note:

• The documents are intended as a ‘system’ documents (i.e. a working draft to be shared between partners) which are in the public domain, rather than a document designed for the public. A public version will be developed as part of the next stage of the process.

• These sections build on local plans and are being shared early on with partners and in public in the spirit of transparency and for constructive comment and iterative development.

• These are the first working draft of the sections and are the output of discussion and debate through a series of system review groups.

• These sections have not yet been fully cross referenced with each other for interdependencies.

• These are yet to be fully costed and financially modelled although have been developed in line with current funding assumptions.

• This draft does not yet represent finalised policy positions. The document will undergo significant change through a series of drafting iterations.

75151

http://www.northlondonpartners.org.uk/ourplan/the-nhs-long-term-plan.htm

Delivering a service model for the 21st century:

PCN development and building community capacityHealth and Care Closer to Home brings together system partners from primary, community, and acute services, local authority, commissioning and the voluntary sector via its Programme Board.

7

Development of PCNs

All mainstream primary care services are included in PCNs. There is now full coverage across NCL, with 30 PCNs (Barnet 7; Camden 7; Enfield 4; Haringey 8; Islington 4), based on geographical contiguity between practices; many are on the same footprint as the earlier CHINs/ neighbourhoods. As integrated care partnerships develop at borough level, community providers will configure teams on thesame footprints and develop a roadmap to ensure readiness to deliver the anticipatory care PCN DES specification from April 2020.

PCNs are at varying stages of maturity. Clinical Directors are currently diagnosing the support they will need to develop the PCN, which will inform how development funding is allocated. The emerging themes are:• Organisation development and change• Leadership development support (inc Clinical Directors)• Supportive collaborative working (MDTs)

Developing workforce and capacity in the community

Our NCL workforce programme, and specific Health and Care Closer to Home workforce action plan, describe our plans to develop, retain and recruit our workforce. We are using tools such as e-rostering, standardisation of shift patterns and the adoption of Care Hours per Patient Day to better understand our staffing requirements.

Our digital programme includes the introduction of a population health management approach, a health information exchange across NCL, and the development of a patient-facing digital record, and the development of digital and telephony-based services, which will increase capacity and support delivery of more efficient care In one borough, work is underway to align the community health care service system with that of GPs to include e-referrals, e-care plans and shared care planning. HealtheIntent is a local digital solution to support effective anticipatory care at a population level, which will integrate near real time data to deliver actionable analysis for anticipatory or proactive care.

• Population health management • Social prescribing and asset-based community development• Identifying, evaluating and sharing learning

5252

Delivering a service model for the 21st century: community crisis response and anticipatory care

7

Community health crisis response within 2 hours and reablement care within 2 days

We have established a crisis response model from 8am-8pm, 7/7, and are working with our three community providers to ensure a high degree of consistency including standard approaches to referral, eligibility criteria and operating hours. This is already being achieved in some boroughs, but not all. We will seek to include a standard contract KPI across the 5 boroughs from 20/21.

We are working with local authorities to ensure reablement care is delivered consistently within 2 days. Health-based communityreablement is delivered same day in some but not all of our boroughs currently. We are seeking to increase the speed that patients access community-based rehabilitation. A transition plan for contractual KPIs will see a shift from an expectation of a 2 week wait to a 2 day wait by 2023.

Bed-based rehabilitation has varied, and significant work has taken place to embed an effective Discharge to Assess model with an emphasis on ‘home first’. Further work is being undertaken in each borough with local authorities. Bed-based rehabilitation is often dependent on local authorities locating appropriate accommodation for patients deemed to require a supported care arrangement.

Anticipatory care by integrated primary and community services, together with local authority and voluntary sector providers

We have developed effective models of practice around a number of different patient cohorts (e.g. frailty, long term conditions, SMI), and each borough has developed MDT working with key elements of the health and care closer to home approach embedded (population segmentation / development of register, proactive case finding based on risk, outreach, care planning, MDT review and proactive case management, support to self care and self manage. Further work in 19/20 will develop the contribution of community providers, including caseloads, and operating policies. Some community health services are exploring operating from GP premises, including services for MSK, diabetes and asthma Self care is central to the plans. We have introduced the Patient Activation Measure (PAM) in one borough, focussing first on all care planned patients. This links to wider work on embedding the personalised care to spread best practice on the different elements of the universal personalised care model across NCL. We will further review the models of care as further detail of national specifications are published.

5353

Delivering a service model for the 21st century: Enhanced health in care homes

7

Enhanced health in care homes

The 230 care homes in NCL are an important part of our health and care infrastructure, with care homes providing homes to 6,000 of our frailest residents outside of hospital (there are more care home beds than NHS beds in NCL). There is uneven distribution of care homes across NCL; around 90 care homes in Barnet (>70% of care home beds in NCL are in Barnet and Enfield), only 8 within Islington. There is a range of locally commissioned services for care homes across NCL, including GP in-reach, MDT support and a range of quality and workforce initiatives to support care homes. There are different models of care in each borough and some gaps, for example, benchmarking identified considerable variation in primary care input to care homes between boroughs, such as access to a named GP. NCL’s care home residents experience high acute admissions and LAS call outs, costing our CCGs £42m in 2017/18. This is above peer benchmarks and the London and national averages.

Working in partnership with the Local Authorities, NCL CCGs are working to join up health and social care and dedicated services in this area. The intention is to shift the reactive, expensive reliance on acute care, to a pro-active community based model that delivers betteroutcomes and meets the LTP ambition for consistent service delivery against the EHCH Framework by 23/24. This includes:• an innovative workforce programme that is supporting social care providers to recruit and retain staff, develop progression pathways

that increase staff skills and leadership capacity, which will support the NHS to meet the health care needs of care home residents.• actions that will support PCNs, including commissioning a care home dashboard to give us up to date information on activity

levels and quality; contributing to the development of the national PCN DES specification for EHCH, (some parts of NCL are likely to commission above this already).

• a Darzi fellow starting in September 2019 focusing on care homes to bring the system together to co-design and implement a new model for primary care input in line with the EHCH framework. This will strike a balance between standardisation of systems and processes, and necessary adaptation to local context, to address unwarranted variation.

5454

A focus on prevention:

Smoking and Alcohol

7

SmokingAround 14% of people across NCL smoke, varying from 10% in Barnet to 17% in Haringey. It is the single largest cause of health inequalities and premature death. There is significant variation in the availability and capacity of smoking cessation services; each borough commissions smoking services differently, both in the community and secondary care. Services are accessed through a range of providers, and residents can access the London-wide Stop Smoking portal.

We are developing a system-wide map of current investment, service delivery, and stop smoking activity and outcomes across secondary care providers in NCL, alongside LA-commissioned community cessation services to identify gaps and investment requirements, ranging from the identification of smokers, provision of brief advice, provision of pharmacotherapy, and onward referral into community stop smoking support. We are exploring opportunities to reduce variation through initiatives such as developing a NCL smoke free policy and options to standardise very brief advice training. Smoking in pregnancy has already been identified as a priority and a joint programme of work is being delivered by a partnership of maternity services, public health, service users, and stop smoking services across NCL.

AlcoholNCL has some of the highest rates of alcohol specific admissions in London with Camden and Islington significantly worse than London and England. Haringey, Camden and Islington also have some of the highest death rates for alcohol related mortality across NCL.

There are some excellent alcohol support services (including preventative and treatment services) across community, primary and secondary care, like commissioned online support (Barnet, Camden, Haringey and Islington), community outreach teams (Camden, Haringey and Islington), formalised detox and recovery services (Barnet, Camden, Haringey and Islington). The LTP highlights ACTs as being an effective approach to preventing alcohol related harm. Within NCL, services for alcohol liaison play a similar role to ACTs (in Camden, Haringey and Islington), funded by boroughs and situated in the local acute trusts, which are improving outcomes and a good return on investment. However, there is variation across NCL and where there are good services being provided, there are opportunities to upscale and reach a larger proportion of those in need.

5555

A focus on prevention:

Obesity, Air pollution and Antimicrobial resistance

7

ObesityBeing overweight is partly responsible for more than a third of all long term health conditions in NCL, with two of the five NCL boroughs (Enfield and Haringey) having a higher obesity prevalence (those with BMI of 30+) amongst 16+ than the London average. NCL’s National Diabetes Prevention Programme is now provided by a single provider, which includes a more comprehensive face-to-face behaviour change programme and a digital platform. Local public health teams will support general practice to maintain referrals into the programme and improve equity of access, particularly to reduce variation and inequalities with ‘at risk’ groups. Adults and children have access to NICE recommended Tier 1 and Tier 2 weight management support in four out of five NCL boroughs through community andprimary care initiatives, funded by local public health teams. There are no Tier 3 specialist support in NCL. We will look to develop a system business case for tackling this. There are system approaches targeting the obesogenic environment through sugar reduction, nutrition advice, physical activity schemes and promoting a healthy urban environment.

Air pollutionThe fraction of mortality attributable to air pollution particulate matters in NCL vary from 6.3% in Barnet to 6.9% in Islington, compared to 5.1% in England. Specific projects across NCL include work with schools, focus on Active Travel plans linked with local Transport Strategies and Local Implementation Plans, Healthy Streets approach, AirText messaging to residents that link with primary care, installing new electric charging points, and a health and care wide partnership on paediatric asthma pathways. Additional work will look at supporting NHS Trusts to sign up to the Clean Air Hospital Framework, and reduce business mileage and fleet air pollutant emissions.

Antimicrobial resistanceNCL CCGs are prescribing significantly below the national target of reducing antimicrobial use by 15% from the current national rate. Camden is the only borough achieving the target of broad spectrum antibiotics of less than 10% of the total antibiotics prescribed. 2018/19 AMR CQUIN data for NCL Trusts demonstrated improvements in total antibiotic usage - many found it difficult to reduce total carbapenem usage. The future focus will build on this and include: GP prescribing of broad spectrum antibiotics;healthcare associated Gram-negative blood stream infections and reducing UTI infections; evolving the Antimicrobial Pharmacists Group to become a multidisciplinary strategy group providing system wide leadership; establishing and improving antifungal stewardship; education & training; scoping work with all providers to support delivery.56

56

Improving mental health outcomes (i)

7

AmbitionsNCL’s vision for mental health support is based on the principles established by our Expert by Experience Board. The ambitions are:• Improved access to care and support (embedding “no door is the wrong door”; addressing significant areas of unmet need; provide

support in the interim where people are on waiting lists for complex care treatment,; better coordination of access to specialist support once patients are discharged from secondary care, and develop fast track access to specialist mental health teams in a crisis)

• Service provision and development (reducing variation in support services; a greater community support offer and Crisis Cafes; stronger support and funding for the Voluntary and Community Sector, while subject to the same outcome measures as statutory services; transparency in addressing gaps in service provision and supporting people who require “complex care/the level above IAPT but below crisis intervention”, expanding the workforce particularly peer support roles)

• Outcomes and monitoring (increased focus on patient-centred goals like patient recovery outcomes, housing and employment, patient and public participation in evaluation and monitoring of services)

Strategic approach• Provider collaboratives: there are three NHS Provider Collaboratives in development that are aiming to take over NHSE Specialised

Commissioning budgets. The main objectives are to ensure: care closer to home through the elimination of external placements;incentives for community care; joined up pathways with secondary / primary care; providers in North London working as a system not in competition. All three have had their interview with NHSE following the first stage of the approval process and are awaiting feedback. If they progress into the fast track, they will need to submit a final business case by November with a start date of April 2020. They will be engaging with local authorities, CCGs and the NCL Transforming Care Partnership.

• Stabilising and expanding community teams: (i) implementing a new digital system across NCL, including a registry for physical health checks for adults with Serious Mental Illness, and automating identification of GP practices with low completion rates of healthchecks for this cohort, improving the support available for these practices and their patients through existing QUIST initiatives; (ii) expanding primary care workforce and further upskilling, including links to specialist support from mental health trusts, enabling the expansion of health checks and looking at further evidence of effective interventions that can be facilitated in part with Personal Health Budgets for this group; (iii) Individual Placement and Support services are available across NCL. The access standard for Early Intervention in Psychosis is already met across NCL and Service Development and Improvement Plans are now in place to ensure all services achieve Level 3.57

57

Improving mental health outcomes (ii)

7

• Initiatives via additional fair share funding to expand access: • CYP aged 0-15 services: NCL has good examples to learn from, including an open access / voluntary service models called ‘HIVE’ in

Camden and ‘Choice’ in Haringey, with principles, which could be replicated across the STP. • access to specialist community perinatal mental health services: NCL is collaborating to deliver a specialist community perinatal

mental health service for women with severe or complex mental health needs. Evidence-based care pathways operate locally and there are examples of initiatives that continue to inform the development of the new service, which will continue to focus resources and engage people who find help harder to access including teenagers and mothers from some BME groups including those for whom English is not their first language.

• 24/7 adult crisis resolution and home treatment teams (CRHT): there is 100% coverage of CRHT services which operate on a 24/7 basis and include Crisis Single Point of Access functions in addition to Home Treatment and Assessment teams. Camden and Islington also have a specialised Older Adults Home Treatment Team. CRHT provision will be able to deliver a high-fidelity service by 2021, maintain high-fidelity coverage of UCL Core Fidelity scales to 2023/24. There is a commitment to review Crisis Pathways inBEH; strengthening CRHT Teams and providing care closer to home will be critical to managing the increasing pressures on inpatient beds and to reducing out of area placements.

• CYP mental crisis services: NCL will develop a local integrated pathway for children and young people with higher tier mental health needs, including rapid community-based and out-of-hours responses to crisis. Investment will focus on expanding the crisis workforce and training for the crisis response team, with a focus on Dialectical Behaviour Therapy (DBT).

• Alternative crisis provision: current provision across NCL is varied. The planned transformation funding will evolve alternative crisis services to become increasingly uniform and equitable across the STP to all age groups for people, and their carers.

• Initiatives via additional targeted funding allocations (to be agreed with NHS England and NHS Improvement): • Salary support for IAPT trainees: IAPT trainee numbers have been agreed across NCL, with contract variations in place to

provide salary support in line with regional funding requirements.• CYP mental health support teams: all five boroughs in NCL had successful bids for Mental Health Support Teams

in schools trailblazer sites. Camden and Haringey went live in late 2018, Enfield go live in September 2019, and Islington and Barnet will go live in January 2020.

• Maternity outreach clinics in 2020/21 and 2021/22 5858

Improving mental health outcomes (iii)

7

• Initiatives that could be funded via additional targeted funding allocations (to be agreed with NHS England and NHS Improvement): • New models of integrated primary and community care for adults and older adults with SMI: this is central to the joint clinical

strategy by our mental health trusts over the next six months. Developments in community provision will continue over the next two years through transformation funding, using devolved specialised commissioning budgets, and expanding Primary Care MentalHealth services across NCL.

• Mental Health Liaison Services: these are delivered 24/7 in all 5 Acute sites in NCL, with a commitment to consolidate and expand MHLS. Partners have adopted a MHLS Collaborative Agreement, Core 24 service specification and associated KPIs. This system wide approach has attracted Wave 2 MHLS transformation funding to enhance provision and ensure all hospitals in NCL meet Core24 Standards for adults and older adults by 2021.

• Individual Placement Support (IPS): services are available across NCL following close working between health and social care, and a further two-year expansion will be supported through Wave 2 funding to extend access in primary and secondary care.

• Testing of clinical review of standards in 2019/20 (TBC)• Model for problem gambling: NCL was not successful in securing problem gambling funding in 19/20. It is considered a future

ambition due to established existing services and ability to expand the model. • Specialist Community Forensic Care and women’s secure: North London Forensic Consortium will be a wave 2 pilot site for the

new specialist community forensic team model, which will be rolled out over a 2-3 year period, initially covering Barnet, Enfield and Haringey, expanding to Camden and Islington from 2022/23. It will support development of accommodation pathways by co-commissioning housing providers, which will reduce length of stay for forensic inpatients, improve housing pathways and increasecommunity resource.

• Enhanced suicide prevention initiatives and bereavement support services: NCL successfully bid for PHE funding to develop a post-intervention suicide bereavement support service. Procurement will take place by March 2020.

• Mental health services to support rough sleepers: Haringey is a national pilot site and has taken an integrated multi-disciplinary approach to co-produce services for rough sleepers. It will integrate existing homelessness services in a co-located outreach teams. It will further integrate with health services (including GPs, Psychiatrists and Psychologists, occupational therapists, peer support workers) and integrated substance use treatment pathways to ensure effective holistic support. An MDT led by public health developed a funding proposal for Camden and Islington but was unsuccessful. It is a priority for future funding.59

59

26

Appendix 2: • Summary of the Long Term Plan

• Fair Shares allowances• London Vision

6060

Headlines from the NHS Long Term Plan (Jan 2019)

The NHS will increasingly be:• more joined-up and coordinated in its care• more proactive in the services it provides• more differentiated in its support offer to individuals.

Five major, practical changes to the NHS service model over the next five years:• Boost ‘out-of-hospital’ care and reduce primary and community health services divide• Redesign and reduce pressure on emergency hospital services• People will get more control over their own health, and more personalised care• Digitally-enabled primary and outpatient care will go mainstream across the NHS• Local NHS organisations will increasingly focus on population health and local partnerships with

local authority-funded services, through new Integrated Care Systems (ICSs) everywhere.

The NHS Long Term Plan describes transition to Integrated Care Systems. This would be supported by a single CCG in the North Central London area.

6161

Fair shares allocations and Targeted funding

The framework sets out the national funding which will be allocated to systems on a fair shares basis and provides an indication of the national total for targeted funding, to support specific projects.

The details of the requirement linked to the fair shares distribution and targeted funding are on the following slides.

System plans must set out how they will use their resources to deliver the commitments within the NHS long-term plan and meet the financial tests set out within it. This will include detail on the NCL Medium Term Financial plan required as the NCL system is in deficit.

Plans must also incorporate system actions to maximise efficiencies and support appropriate reductions in growth of demand.

In addition, spending plans must be consistent with the commitments to increase investment in certain areas such as mental health, primary medical and community health services.

76262

LTP allocations: Fair Share detail on requirements

The commitments to be delivered through the fair shares funding are as follows:

7

Mental Health The expansion of community mental health services for Children and Young People aged 0-25; funding for

new models of integrated primary and community care for people with SMI from 2021/22 onwards; and

specific elements of developments of the mental health crisis pathways. See 2.27.

Primary Care This funding includes the continuation of funding already available non-recurrently to support Extended

Access and GP Forward View funding streams, (e.g. practice resilience programme), and associated

commitments must be met. Additional funding is also included to support the development of Primary

Care Networks.

Ageing Well Deployment of home-based and bed-based elements of the Urgent Community Response model,

Community Teams, and Enhanced Health in Care Homes.

Cancer Rapid Diagnostic Centres funding in 2019/20 only; Cancer Alliance funding to support screening uptake

delivery of the Faster Diagnosis Standard and timed pathways, implementation of personalised care

interventions, including personalised follow up pathways and Cancer Alliance core teams.

CVD, Stroke and Respiratory Increased prescribing of statins, warfarin and antihypertensive drugs;

Increased rates of cardiac, stroke and pulmonary rehabilitation services; increased thrombolysis rates;

and early detection of heart failure and valve disease.

CYP & Maternity Local Maternity Systems funding; Saving Babies Lives Care Bundle funding from 2021/22; postnatal physio

funding from 2023/24; funding for integrated CYP services from 2023/24.

LD Autism Funding for rollout of community services for adults and children and keyworkers from 2023/24.

Prevention Tobacco addiction - inpatient, outpatient/day case and Smoke Free pregnancy smoking cessation

interventions.

6363

LTP allocations: Targeted funding detail on requirements The commitments to be delivered through targeted funding are as follows:

7

Mental Health Includes:

- funding for continuation of previous waves such as mental health liaison or Individual placement support funding; pilots as part of

the clinical review of standards, and other pilots such as rough sleeping.

- funding to be distributed in phases in consultation with regional teams including: funding for testing new models of integrated

primary and community care for adults and older adults with severe mental illness, community based integrated care, rolling out

mental health teams in schools and salary support for IAPT trainees.

Primary Care Digital First Primary Care support funding; the Investment and Impact Fund; and Estates and Technology Transformation Programme.

Ageing Well Targeted funding to accelerator STPs to rollout the Ageing Well models.

Cancer Development and roll out of innovative models of early identification of cancer (starting with lung health checks); funding for the

development of Rapid Diagnostic Centres from 2020/21 onwards; support for further innovations to support early diagnosis.

Technology Revenue funding for Provider Digitisation and Local Health and Care Records.

Cardiovascular Disease,

Stroke and Respiratory

Pilots for improving access to cardiac, stroke and pulmonary rehabilitation services and early detection of heart failure and valve

disease.

Maternity and

Neonates

Continuity of carer for BME and disadvantaged women from 2021/22; funding to support the UNICEF Baby Friendly Initiative; funding

to support the expansion and improvement of neonatal critical care services from 2021/22; funding from 2020/21 for Family

Integrated Care; funding to support the rollout of postnatal physiotherapy and multidisciplinary pelvic health clinics from 2021/22 to

2022/23.

Diabetes Funding to pilot the use of low calorie diets from 2019/20 until 2022/23; funding to support delivery of recommended treatment

targets; funding for multi-disciplinary foot care teams and diabetes inpatient specialist nurses (see 4.31).

Learning Disabilities

and Autism

Funding to pilot and develop community services for adults and children and keyworkers from 2020/21 to 2022/23; piloting of models

to expand Stopping Treatment and Appropriate Medication in Paediatrics (STOMP-STAMP) programmes from 2020/21 to 2023/24;

testing the model for ophthalmology, hearing and dental services to children and young people in residential schools from 2021/22;

funding to reduce the backlog of the Learning Disabilities Mortality Review Programme (LeDeR).

Personalised Care Targeted transformation funding to deliver the NHS Comprehensive Model for Personalised Care from 2019/20–2021/22.

Prevention Alcohol Care Teams from 2020/21 to 2023/24; Tobacco addiction services early implementer sites from 2020/21; targeted support for

weight management service improvements from 2020/21. 6464

The London Vision (2019)

The London Vision will focus on areas that only a partnership at London level can address, to make sure:

• Londoners get better outcomes regardless of who they are or where they live • Mental health is treated with the same importance as physical health • Londoners have greater control and choice of their health and care• People receive good joined up care throughout their life regardless of which organisation provides the service

Over the coming months priorities and goals will be set. The work being undertaken across London and will feed into the plans in North Central London.

Emerging Priorities1. Reducing childhood obesity2. Improving mental health of children & young adults3. Reducing inequalities and preventing illness4. Improving air quality5. Improving sexual health6. Reducing the impact of violent crime7. Improving mental health 8. Improving the quality of specialised care9. Making health and care more personalised and joined up at every stage of a Londoner’s life from birth

to end of life 10. Improving the health of homeless people

86565

32

Appendices 3: Detail on resident engagement

6666

NCL Long Term Plan: Engagement Plan

Key inputs, outputs and activities

March – June 2019 June – Aug 2019 Sept-Oct 2019 Nov 2019 –Apr 2020Oct–Feb 2019

Resident engagement phase three

Resident engagement phase two

Resident engagement phase one

Baseline Publish plan

NCL Integrated Care -engagement events

Healthwatch engagement surveys and focus groups

Ongoing engagement through NCL workstream boards

Online stakeholders survey

Borough level targeted engagement with priority groups informed by Healthwatch

NCL STP partners staff briefings on LTP and Change programme

Regular engagement with governance groups (HWB, JCC, JHOSC, CCGs governing bodies)

Engagement on CCGs merger with stakeholder and partners

Borough level engagement with PPGs and citizens panel

Partners and stakeholders staff and residents

engagement on the draft NCL delivery plan

Residents’ representatives, experts by experience and CCG lay members engagement

Refining “I” statements informed by Healthwatch

reports

Draft plan

Final plan

Engagement Advisory Board

6767

6868

Barnet CCG Governing Body Meeting 19 September 2019 Report Title NCL CCGs – Case for Change for Merger to

Single CCG Agenda Item

3.2

Lead Director

Ian Porter - Director of Corporate Services for NCL CCGs


GB Member Sponsors

Dr Charlotte Benjamin – Chair of Barnet CCG Dr Neel Gupta – Chair of Camden CCG Dr Mo Abedi – Chair of Enfield CCG Dr Peter Christian – Chair of Haringey CCG Dr Jo Sauvage – Chair of Islington CCG Helen Pettersen - Accountable Officer for NCL CCGs

Report Author

Luke McCartney, Head of Programme Management, NCL Change Programme



Simon Goodwin Chief Finance Officer, NCL CCGs

Summary of Financial Implications This paper sets out a high level summary of the benefits of merging to a single CCG for North Central London.

Report Summary

This paper provides an overview of the Case for Change for the merger of the five CCGs in North Central London to form a single statutory organisation. The paper will form the basis of the proposal to be submitted on 27 September 2019 to NHS England - which will constitute our formal application to merge. The paper summarises that progressing the merger for April 2020 will enable us to:

1. Accelerate our work to build new ways of working across the system; 2. Build a more efficient and effective operating model; 3. Make better use of our resources for local residents and achieve

economies of scale; 4. Support the development of local, borough-based Integrated Care

Partnerships and primary care networks; 5. Become a larger organisation with much greater resilience; 6. Provide a single, strong and consistent vision / voice for our partners; 7. Enable greater opportunities for working together as ‘one NHS’ –

ultimately delivering improved patient outcomes for our population and reduce health inequalities.

The benefits of the merger will include: Greater efficiency (short / medium term); The ability to better support the move to new ways of working (short /

medium term); Delivering better outcomes for patients (medium / long term).

6969



The paper also provides details on the plan for delivering the merger, and for the supporting communications and engagement work. Appended to the paper are a series of documents which provide an overview of how the new organisation would function – focussing on:

Proposed approach to Patient and Public Engagement; Proposed Financial Strategy and arrangements for delegated decision-making;

Further governance arrangements. The appendices also include:

A transition schedule setting out the key next steps in establishing the governance required for the new organisation;

Letters of support for the proposed merger from partners.

Recommendation The Governing Body is asked to SUPPORT the submission to NHS England on 27 September 2019 of the formal application of the NCL CCGs to form a merged CCG for North Central London from 1st April 2020.


A robust programme management approach has been established for the North Central London Change Programme, including an approach to risk management / risk register that has been reviewed and approved by the NCL CCGs’ Assurance and Oversight Group. A summary of this can be found in section 2 of the report. In addition, a single risk relating to the delivery of the merger is included on the NCL Corporate Risk Register for all CCGs.


It should be noted that the Governing Body is asked to support the application to merge the five CCGs, not approve it. Final approval of merger applications rests with NHS England and therefore removes Governing Body members’ potential conflicts of interest.


Resources are already in place to deliver the merger as part of the NCL Change Programmes, including leadership from the NCL CCGs’ Senior Management Team and the establishment of a single programme team.

Engagement

An extensive engagement process has been conducted at CCG and NCL level to ensure that all partners are aware of, and have had the opportunity to feedback on, our plans for merger. A summary of the communications and engagement plan to support the merger, engagement activity that has been undertaken, and feedback received, is set-out in Section 3 of the report. Appendix E includes letters of support for the proposed merger received to-date from the CCGs’ key partners.


We recognise that any change to the way that CCGs operate has the potential to impact on equalities. For this reason, an independent equalities impact assessment has been commissioned to review the impact of the proposed merger – with key focus on:

Governance and decision making for the proposed CCG; Maintaining the resident voice.

Section 1 of this report includes the outputs from this work and recommendations for associated next steps.

7070

The report also highlights the importance, from an internal perspective, of the proposed new CCG fully embracing all aspects of equality, diversity and inclusiveness – including to support staff and office holders in their roles.


The content for this report has been developed with key input from Governing Body members, at the following sessions:

Governing Body Seminars in May 2019 Assurance and Oversight Group on 25 July 2019 Governing Body Seminars in August 2019 Assurance and Oversight Group on 20 August 2019 Monthly meetings between the CCG Chairs and Accountable Officer

(since March 2019). The CGGs’ lay members with lead responsibility for Patient and Public Engagement (PPE) have provided key input into the content related to the proposed PPE approach for the single NCL CCG.

Next Steps The report is being presented at each of the CCG Governing Body meetings during September. The next steps after this are as follows:

27/09: Submission of formal application for merger to NHSE 30/09: Full development of merger implementation plan for next phase 09/10: Attend NHSE England Formal Assessment Panel 10/10 – Next meeting of the NCL CCGs’ Assurance & Oversight

Group (meets monthly until merger is complete - to oversee and assure the transition)

25/10 – Membership vote closes on new constitution for single NCL CCG

01/11 – Formal feedback expected from local and national NHSE teams

01/04 – Merger takes place

Appendices

The following appendices are included with the report:

Appendix A: Our Approach to Patient and Public Engagement

Appendix B: Our Financial Strategy & Arrangements for Delegated Decision-Making

Appendix C: Further Governance Arrangements

Appendix D: Governance Transition Plan

Appendix E: Letters of Support from Partners

7171

7272

North Central London CCGs

Proposal for Merger of NCL CCGs P a g e | 1


Governing Body Paper:

Proposal for Merger of NCL CCGs

7373



Contents 1. Our Case for Change ........................................................................................................................ 3

Executive Summary of Benefits ........................................................................................................... 3

Our Strategic Commissioning Approach .............................................................................................. 5

The NCL CCGs .................................................................................................................................... 10

The Profile of the New Proposed CCG ............................................................................................... 10

Our Local Population ......................................................................................................................... 11

Our Public Sector Equality Duty (PSED) ............................................................................................. 12

The Drivers and Benefits of Merging ................................................................................................. 16

Our History of Joint Working ............................................................................................................. 19

Communicating and Engaging on Our Merger Plans ......................................................................... 20

Support for Merger ........................................................................................................................... 21

Intervention and Delegated Authority .............................................................................................. 22

2. Our Approach to Delivering the Merger ......................................................................................... 23

3. Our Merger Communications and Engagement Plan ...................................................................... 28

Appendix A: Our Approach to Patient and Public Engagement ............................................................... 34

Appendix B: Our Financial Strategy & Arrangements for Delegated Decision-Making ............................ 38

Appendix C: Further Governance Arrangements .................................................................................... 45

Appendix D: Governance Transition Plan ............................................................................................... 50

Appendix E: Letters of Support .............................................................................................................. 51

7474



1. Our Case for Change

We believe there is a strong case for merging the CCGs in North Central London into a single statutory body from April 2020. This will enable us to:

1. Accelerate our work to build new ways of working across the system

2. Build a more efficient and effective operating model

3. Make better use of our resources for local residents and achieve economies of scale

4. Support the development of local, borough-based Integrated Care Partnerships and primary care networks

5. Become a larger organisation with much greater resilience

6. Provide a single, strong and consistent vision / voice for our partners

7. Enable greater opportunities for working together as ‘one NHS’ – ultimately delivering improved patient outcomes for our population and reduce health inequalities.

A key driver for the merged CCG will be to deliver commissioning functions at the most effective level for the benefit of improving patient outcomes and reducing health inequalities.

The proposed CCG will take a multi-layered approach with planning and commissioning being co-ordinated at an NCL level, led by the Governing Body, its committees and borough-based boards or sub-committees. Organisational design will support both NCL-level and borough-based working.

This document sets out the reasons for merging, an overview of the proposed new CCG and how it will operate, and the benefits and impacts of merger.

Executive Summary of Benefits

1 - Accelerate our work to build new ways of working across the system

Building on our work with partners on the future of health and care across North Central London, and in line with the NHS Long Term Plan, the CCGs will need to move to a new, more strategic commissioning model and support the development of integrated partnerships at a borough level. The boroughs will in turn have an important role in supporting sub-borough frontline integration and development of services.

As part of this new way of working, we will need to move to new ways of planning and paying for services and take a population based approach to healthcare. This will mean the development of longer term outcomes frameworks set for populations, based on health inequalities and priorities that take into account the wider determinants of health, not just service or contract based key performance indicators. This would also mean that some of the functions traditionally undertaken by both commissioners and providers, would be undertaken once for the system.

2 - Build a more efficient and effective operating model

The current NCL operating model, with a shared Accountable Officer and CFO with joint CCG committee structures in place for acute commissioning, primary care commissioning and audit, provides a strong existing base to support the merger of the CCGs. However there are elements of duplication across organisations and decision making can be slow. This also means that transformation is not taken forward consistently, or at pace across all of NCL – all of which would be addressed under a merged CCG.

The new operating model, will need to take into account the above points – with a key principle being to deliver functions at the most effective level including those areas most suited for borough-level

7575



delivery (e.g. primary care commissioning) and NCL-level delivery (e.g. acute commissioning). The model will deliver a flexible, more efficient commissioning function and support borough integration. This is reflected in the proposed, new single executive team. The application to merge the CCGs will formalise the new ways of working and governance associated with this and support the effective delivery of this new way of working.

3 - Make better use of our resources for local residents and achieve economies of scale

The future model looks to centralise certain functions under members of the executive team where there is benefit in a larger planning footprint to maximise the impact for local residents i.e. where doing so will allow best use of resources, deliver efficiencies for the population who will benefit from a coordinated at scale approach. These centralised commissioning functions will need to evolve over time into strategic functions making use of new mechanisms to enable the system and partnerships to deliver on outcomes over longer periods of time. Those functions that are best delivered at a borough level will continue to be overseen at a local level e.g. primary care commissioning.

4 - Support the development of local, borough-based Integrated Care Partnerships and primary care networks

Under the new executive team, the CCG will also have clear borough facing functions with senior leaders based at borough level. The primary role of these will be to work with partners to facilitate the development of borough based partnerships (ICPs). This will mean working together with primary care, community, mental health and social care partners to configure their services around individuals rather than organisations.

Over time, there will be delegation of responsibilities to the local integrated care partnerships. The development of the partnerships, will be an important building blocks around which the NCL integrated care system will be built.

There will continue to be an important interface with borough democratic structures: Health & Wellbeing Boards and overview and scrutiny committees, via senior local NHS staff. At North Central London level we will continue to work closely with the Joint Health Overview and Scrutiny Committee.

5 - Become a larger single organisation with much greater resilience

The development of a single CCG for North Central London will create an organisation with a single staffing base and as a result much greater flexibility to move resources to where they are needed most in the system, to help tackle emerging priorities and challenges. This enhanced resilience will enable the CCG to better support the wider system to manage issues as they arise.

The greater scale of the organisation will also increase the opportunities for staff to grow and develop within the CCG. A single management structure will create the opportunity for a more concerted, strategic and consistent approach to organisational development, staff and office-holder development and staff retention – and enable all colleagues to work to a single set of organisational objectives and values.

6 - Provide a single, strong and consistent vision / voice for our partners

The move to a single CCG will ensure consistency of messages and alignment in our approach to joint working with partners and service providers across the system. The new model will provide a greater degree of influence over the system for the benefits of patients and residents – and this will become increasingly important as we work towards the development of an Integrated Care System for North Central London. There will be a single NHS commissioning voice and vision that will feed into that process, something we know from feedback will be welcomed by our partners.

7676



7 - Enable greater opportunities for working together as ‘one NHS’ – ultimately delivering improved patient outcomes for our population and reduce health inequalities

The development of a more consistent, aligned, efficient, and effective NHS commissioning function for North Central London will ensure that we maximise investment in frontline services and are able to work in a more collaborative way with our partners to facilitate and support improvements in the way healthcare services are commissioned. This, alongside a more strategic and efficient system-focused approach to decision making, will ultimately lead to the improvement in outcomes for our patients and residents and the reduction in health inequalities across the system.

Our Strategic Commissioning Approach

Regardless of the future arrangements for commissioning, there are a number of ‘must- haves’ and

principles, that we are committed to delivering. Mostly these are examples of good practice we are

already doing and form the basis of our draft proposals.

Our ‘Must-Haves’

The ability to deliver our commissioning ambitions and responsibilities effectively and as quickly as possible, both at neighbourhood level and across the entire geography we serve

Strong clinical leadership and involvement in the new arrangements

Effective engagement with local people, clinicians, health and care partners and others to inform commissioning decision making and activities from neighbourhood to system-wide

An ongoing focus on the health and care needs of neighbourhoods or specific populations, as well as a strategic focus across north central London

A single commissioning vision with strategic priorities and health outcome goals at system, place and neighbourhood levels

The opportunity to work effectively with our partners and pave the way for better integration of health and care services, at borough level through integrated care partnerships and at system level through our emergent integrated care system

An efficient, Value for Money commissioning structure that can deliver both the 20% savings in CCG running costs by 2020/21, and support financial recovery and sustainability across the system, including protecting our primary and community care expenditure

The required level of capability and capacity in our clinical, management, and staffing resources to drive forward the changes required and achieve the benefits of merging

Our Principles for the New System

We will work as one system to benefit the whole population of North Central London and work together to drive health equalities. We will agree key areas to systematically focus upon as a single CCG

We intend to move away from the payment by results system, to place-based budgets, based on population need

Where it makes sense and there is a clear benefit to patients of doing so – we will drive efficiency by commissioning a standardised offer to a uniform value with consistent outcomes. We will continue to support local variation where it will help to reduce health inequalities

We will work on a population health management basis, as a system, as local partnerships and as neighbourhoods/ networks

7777



We will retain the local patient, resident and clinical voice in the commissioning and delivery of health and care, by working effectively together at the three levels of our system

We will value our staff, our partners and their expertise to deliver the best health and care possible for North Central London

We will drive forward our integration agenda, to deliver joined-up care for population

We will emphasise the value of subsidiarity, working as locally as is feasible whilst retaining strategic, effective commissioning for North Central London

The development of the NCL CCG will support the delivery of these system-wide principles, culminating in improved outcomes for patients, as set out in the diagram below:

Our Operating Model

We are in the process of developing a new operating model for the single CCG that ensures we deliver on the principles and ‘must-haves’ for both the CCG and the wider system. This has begun with the development of a new Executive Management Team structure for NCL CCG. This builds on the existing joint management structure for the NCL CCGs, but in addition moving to the new Executive Management Structure will enable:

A realistic balance between BAU and the work required to transform and move to new commissioning arrangements.

Increased local capacity for the development of our Borough based Integrated Care Partnerships.

Retention of scarce talent and allowing all boroughs to benefit from this talent. It will also enable continuity during complex change.

Shared senior commissioning leadership capacity and capability to support greater outcomes focus and alignment of contracting.

Improved clinical input at the most senior level with a full time lead for Quality at SMT level.

Retention of corporate knowledge essential for delivering priorities outline within NHS Plan.

The new NCL CCG Executive Management Team structure:

7878



The new arrangements have been confirmed following consultation and the transition process for the portfolios of the Executive Management Team will be confirmed shortly. Work has now commenced on the next stage of design of the CCG operating model and staffing structures, focused on ensuring that the right capacity is in place to deliver the required functions at each level of the model.

How functions might work in the new model

Below we have set out at a high level how the functions in the new operating model could work. This

will be reviewed by the new executive team once in place and will be further updated at this point. It

will need to align with the development of integrated care partnerships and the work on the integrated

care system across NCL.

Features of our multi-layered commissioning approach will include:

7979



The specialised / acute planning and commissioning function being undertaken once across NCL – with associated responsibility, authority, budget and capacity;

The ability and structure that enables commissioning activity and decision-making at a borough-level, where this is most effective to do so. This will include the responsibility, authority, budget and capacity for primary care commissioning (strategy development, planning and commissioning intention) and community care and out-of-hospital commissioning – which will be delegated to borough-level arrangements;

From a decision-making perspective, borough-level groups or sub-committee may be established. These arrangements will help ensure the ongoing strength in local partnership working – helping to maximise commissioning outcomes for patients;

Borough-based teams having an interest in and influence upon NCL commissioning activity - including the generation of borough-level priorities with borough member practices (including through local primary care networks) and clinicians to feed into the development and delivery of NCL wide plans.

Clinical Leadership in the new CCG

The new single CCG for North Central London, and our Integrated Care System, will be underpinned by a strong clinical leadership and engagement model.

The principles that will inform the development of the model are:

A single CCG will allow us to set, implement and monitor a uniform set of clinical standards across NCL, enabling us to drive down the unwarranted variations in care delivery that currently exist and ensure a higher standard of care our residents.

The CCG retains a clinical majority at the Governing Body.

Strong clinical leadership and involving clinicians in making healthcare decisions are essential aspects of commissioning.

All GP practices are members of a CCG and have a say in what, and how, local NHS services are provided.

There are outstanding examples of clinical leadership across NCL already and we will seek to learn from and build upon the best approaches already in place in the existing CCGs.

We will seek to ensure we have the right level of clinical resource and input at each level in the new system including the borough based ICPs and Primary Care Networks.

Governance arrangements

Robust, transparent and efficient governance arrangements will be at the heart of the North Central London CCG.

The Governing Body will be the primary decision-making vehicle for the NCL CCG – supported by eight Governing Body Committees reporting into it. These are set out in the below diagram. This governance model also highlights the importance of making links to the emerging borough-based partnerships.

8080



The Governing Body (GB) of the NCL CCG will meet on a minimum of 4 times per year, with the discretion to meet at more frequent intervals, as required. The Governing Body will have a clinical majority and comprise 17 Voting Members:

Elected roles

o 10 Elected Clinical Representatives (2 from each Borough area)

Appointed roles

o 1 Secondary Care Consultant

o 1 Registered Nurse

o 1 Lay Member with a lead NCL portfolio overseeing key elements of financial management, audit and governance

o 1 Lay Member with a lead NCL portfolio championing patient and public involvement

o 1 Lay Member with a general NCL portfolio including, for example, to champion the CCG’s work on equalities, diversity & inclusion and the CCG’s delivery of its annual QIPP programme.

Executive Director roles

o 1 Accountable Officer

o 1 Chief Finance Officer

Attendees (non-voting)

o Other Executive Directors on the NCL Executive Management Team

o 1 Healthwatch representative from across NCL

o 1 Director of Public Health from across NCL

o 1 local authority Councillor from across NCL

8181



Whilst not mandatory, we will look to encourage each of the Healthwatch, Director of Public Health and local authority Councillor representation being from different boroughs across the North Central London footprint.

It should be noted that:

The Chair of the GB will be from one of the 10 Elected Clinical Representatives. The Chair will be elected following a vote of all voting members of the GB;

The Deputy Chair will be appointed by the GB Chair from one of the Governing Body Lay Members;

The GB will appoint a Clinical Vice-Chair (from the remaining elected clinical representatives);

The Chair and Clinical Vice-Chair should not be from the same borough area;

The move to a single CCG will provide opportunity for consistent arrangements across North Central London for GB members’ terms and conditions.

Further details on proposed governance arrangements for the new CCG (including on local decision-making) are set-out in Appendix B and C.

The NCL CCGs

North Central London is a diverse area covering five local authorities and five co-terminus Clinical Commissioning Groups, 12 Trusts and 204 GP practices.

The Profile of the New Proposed CCG

It is proposed that the merger of the CCGs will lead to the creation of a new single statutory organisation:

NHS North Central London Clinical Commissioning Group.

The new CCG will:

Have 204 GP Practices as members

8282



Be coterminous with five local authorities

Be lead commissioner for 4 major acute trusts and 2 mental health trusts

Include within its geography 4 major specialist tertiary centres

Serve a resident population of 1,422,000 people

Serve a GP-registered population of 1,613,078 people

Be allocated £2.1bn to spend on core health and care services for our populations in 2020-21

Be allocated £227m per year to spend on primary medical services in 2020-21

Our Local Population

NCL is a diverse area containing both some of the most deprived and more affluent populations in the country. Across North Central London we face differing issues on health inequalities within each borough.

High level population statistics

30% of NCL children are growing up in poverty1

Islington, Enfield and Haringey have the highest rates of deprivation relative to the national picture, although pockets of deprivation are dispersed across all boroughs in NCL2

At ward level, the highest forecast population growth is Upper Edmonton in Enfield and Golders Green in Barnet3 due to development at Meridian Water in the Lee Valley in Enfield and around Brent Cross in Barnet

Housing and population growth is concentrated in specific locations. There are currently seven housing Opportunity Areas in the NCL geography (numbers show new homes in 2018 draft London plan):

o Colindale / Burnt Oak (7,000)

1 NCL Sustainability and Transformation Plan – Case for Change – September 2016 2 Primary Care Strategy Data Pack – GLA, 2016; North Central London Devolution Pilot Outline Business Case November 2017

8383



o Cricklewood / Brent Cross (9,500)

o Upper Lee Valley (cross border) (21,000)

o City Fringe (cross border) (15,500)

o Euston (2,800 – 3,800)

o Kings Cross (1,000)

o Tottenham Court Road (300)

With two additional areas identified in the draft London Plan (2018) at Wood Green and New Southgate, reflecting the potential for Crossrail 2 to unlock additional housing in those areas3.

Life expectancy and inequality

All NCL residents have seen an increase in life expectancy over the past decade with current life expectancy for men and women across NCL higher than the England average, with the exception of Haringey and Islington. Despite the higher life expectancy, overall, residents spend approximately 20 years of their life living in poor health. Trends in healthy life expectancy show there has not been a significant change in the number of years people are living healthy lives.

There are stark differences in life expectancy between those living in the most affluent areas compared to the most deprived. Across the NCL boroughs, Camden has the highest life expectancy gap for men, with those living in the most deprived areas living on average 10 years less than the least deprived as the image below demonstrates.

Prevalence of long term conditions

Across NCL, the three most common long term conditions are Hypertension (11%), Depression (7%) and Diabetes (6%). Barnet and Enfield have significantly higher prevalence of Hypertension, Diabetes, Coronary Heart Disease (CHD), Chronic Kidney Disease (CKD) and cancer than the NCL averages. In comparison Camden, Islington and Haringey are broadly in line with the NCL averages, although in some cases having higher prevalence of depression and severe mental illness (SMI)4.

Our Public Sector Equality Duty (PSED)

We recognise that any change to the way that CCGs operate has the potential to impact on equalities. For this reason, an independent Equalities Impact Assessment (EIA) on the impact of merger on our Public Sector Equality Duty was commissioned – with the conclusions from this assessment being set out below.

Equalities analysis

To support the proposal for the merger of the NCL CCGs, and to consider the potential impacts on people with characteristics protected under the Equality Act 2010 , plus those who identify as carers and those affected by deprivation, Verve Communications was commissioned to undertake an independent initial equalities analysis. As the process continues further equalities impact assessments should be undertaken to assess the impact of changes as the plans become clearer and further information is available.

Desk research was undertaken for this exercise using documents produced to support the proposed merger and existing data on the populations of the current CCGs.

3 NCL: Growth and S106, HUDU 2018 4 Source: Office for National Statistics 2014/2016 Pubic Health England HSCIC 2015

8484



Scope and objectives

The objective of this work was to carry out an initial impact assessment in relation to two core functions of the CCGs:

Governance and Decision Making

Engaging with the public and hearing the resident voice

The work looks at the current approach and considers some potential benefits and risks to the merger proposals – including in context of the eleven protected characteristic groups.

The output of the impact assessment work provides recommendations on potential mitigations for risks and a timetable for further EIAs.

This equalities analysis is designed to be an iterative process which will be revisited during the process of the merger of the CCGs.

Conclusions from independent EIA

We believe that merging the North Central London CCGs provides an excellent opportunity to tackle health inequalities by working at scale across the NCL population.

Changing governance structures and processes have only an indirect impact on inequalities. However, planning and decision-making on a larger scale across a greater population could enable a step-change: sharpening the focus on equalities impacts and commissioning services which have equalities ‘designed-in’ from the outset.

This would bring direct benefits for residents sharing the nine ‘protected characteristics’ identified in the Equality Act; other groups at risk of health inequalities; and enable a reduction in inequality of provision and outcomes (the ‘public sector equality duty’).

To achieve this, structures and processes must be designed which incorporate: robust and rigorous analyses of the equalities implications of commissioning decisions through equality assessments; a structured approach to the measurement, evaluation and reporting of impacts on different groups and communities; and decision-making appropriately informed by these processes and set in a framework where tackling inequalities is an explicit objective.

The merger will also have an impact through its effect on the CCGs’ engagement with communities and partners, and commissioners’ ability to hear the resident voice.

We would stress the importance of close local liaison and recognise existing strengths and relationships in CCGs in NCL, on which strengthened engagement can be systematically built.

The merged CCG must ensure that local engagement sits within a structured framework. This will enable a richer mix of channels through which to involve residents in planning; develop a deeper understanding of health needs, patient experience, and “what works”; and hear the resident voice at the right time and place to shape decisions.

Beyond this, the merged CCG, coupled with the advent of increasing integration within and across traditional fault-lines in health and care, will enable the wider determinants of health and wellbeing to be supported. Achieving these promises to bring benefits for residents experiencing inequalities or exclusion and support the development of healthy and resilient communities.

We make recommendations in the section below which we believe would support these goals. In developing recommendations, we have considered both the opportunities and potential risks in relation to governance, decision-making and resident voice.

8585



Recommendations from independent EIA:

1. Making shared commitments

Differential priorities across the NCL population – defining equalities clearly

Commissioning decisions must recognise and reflect the differential needs and priorities across the population of NCL. There are statutory responsibilities to consider the needs and preferences of residents sharing protected characteristics and to tackle inequality. Beyond this, the merged CCG should adopt clear policies on meeting the needs of other groups at risk of health inequalities, for example communities with high levels of deprivation, carers or refugees.

Complexity and diversity – developing equalities policies which look outward

The merged CCG should take account of data and insight developed locally and nationally and set equalities policies based on a nuanced understanding of the complexity and diversity of the NCL population, where groups may suffer multiple causes of deprivation or individuals share several protected characteristics. This means equalities policies should be developed from the outset through collaboration with residents and partners and based on an understanding that services commissioned by CCGs sit within a broader system of health and care.

Shared understanding - identifying health inequalities baselines

We recommend an audit of differential health needs and local health inequalities across the five boroughs to provide baselines to enable future commissioning decisions to systematically promote better health equality.

2. Developing processes which will make a difference

Processes - equalities at the heart of decision-making

Commissioning processes should incorporate a clear, structured methodology to ensure that the potential impacts are considered in an effective, proportionate and timely manner to shape decisions. All options considered should be evaluated through rigorous and robust Equality Impact Assessments (EIAs), and decision-making processes should be transparent, accountable and consider equalities explicitly, fully and appropriately.

Subsidiarity – making decisions at the right level

Decisions should be taken at the right level to make the most positive impact possible on equalities. Structures and processes should be based on the principle of ‘subsidiarity’ and designed to recognise the complexity of commissioning decisions and the broad range of voices to be heard. In principle, processes should ensure that decisions are informed through the most local relevant structures possible.

Leadership - clear structures and lines of responsibility

After the merger, lines of responsibility and the mechanisms for ensuring equality issues are considered during decision making should be as clear and straightforward as possible to ensure equality impacts are understood and people can take part in decision making. As well as individual commissioning decisions, individual responsibilities, authority and accountabilities should also be allocated for overall leadership and development of equalities policy, practice and performance across the merged CCG.

8686



Levelling up - building on best practices

An audit across NCL of existing governance and decision-making processes and channels for hearing resident voice should be undertaken. This should focus on identifying examples of current best practices across the five CCGs and developing clear benchmark standards for the merged CCG in agreed key areas. There is much good practice to build on, and within the merged CCG the aim should be to ‘level up’ to meet this. Specifically, no processes in these key areas should be adopted across NCL which would result in a reduction of quality in any existing CCG practice or amount to ‘levelling down’.

3. Working with residents

Representation – building structures to ensure inclusion of protected characteristic groups

Resident voice panels and committees should have formally agreed structures and processes for ensuring that residents sharing protected characteristics are adequately represented.

Supporting people to represent themselves - transparency about resident voice

It should be clear to residents how they are represented on panels and committees and how the panels and committees work. It is important that there is clarity about how resident voice was considered in any decision made.

Focus on resident voice – reviewing local engagement

We recommend that a specific EIA is undertaken on the arrangements to hear resident voice and this should have the active involvement of the NCL PPE committee.

Transparency - about the merger and local involvement

In order to facilitate resident voice, the rationale, process, timetable and expected outcomes for the merger must be explained clearly. In setting the tone for strengthened engagement, it is essential that local people and groups – particularly those sharing protected characteristics or at risk of health inequalities – can participate in the design of engagement and equalities policies and help to shape the development of the merged CCG.

We have made recommendations, above, about future work to be undertaken as the merger progresses and afterwards, including audits of current best practices in the five CCGs in terms of governance, decision making and resident voice - and an audit of current health inequalities across North Central London.

Recommendations for future work

We would also recommend an audit of health outcomes across the NCL CCGs to enable future EIAs to identify key inequalities across the merged CCG.

Over time, and as local integrated care systems mature, it may also be appropriate to evaluate the effects of the merger on the wider determinants of health, for example:

Ways in which the merged CCG could support asset-based community development approaches to tackle existing inequalities

Ways of supporting individuals and developing the social and cultural capital which could enable residents to access services, take a more active part in improving their own health, manage their own care, and build more resilient communities

The effect of the digital workstream on people’s confidence in accessing care

8787



Whether the merged CCG’s priorities and decision-making processes encompass the wider determinants of health and support integration effectively

Identifying specific deprived groups where there are opportunities to deliver broader benefits in health, wellbeing and resilience.

Internal Impact

In addition to the work undertaken by Verve Communications, it is also important to ensure internal ‘equalities’ focus on the merger proposal.

From an internal perspective, whilst there are no direct equality impacts of the decision to support the submission of the merger application – it will be important going forward to ensure that:

The work to implement the new operating structure and establish the proposed new CCG fully embraces high standards with regards to assessing any impacts from an equalities perspective;

On an ongoing basis, the new CCG proactively and robustly embraces all aspects of equality, diversity and inclusion in its operating practices and in supporting staff members and officer holders in their roles.

The Drivers and Benefits of Merging

NCL CCGs have been working together under a joint Accountable Officer and Chief Finance Officer for the last two and a half years. As part of this, some functions have been delegated to NCL wide Committees to support more effective working. Alongside this, the NCL CCGs have been working together with partners on a range of transformational programmes through the STP to build on organisational ambitions which include:

Improving the health and wellbeing of the local population

Reducing health inequalities

Maximising out of hospital care and build resilient, well supported communities

In NCL, significant progress on transforming services, to address the three gaps set out in the NHS Five Year Forward View, has already been undertaken including mental health crisis provision, to consistent and quicker discharge home from hospital, and the development of primary care networks.

Whilst progress has also been made against the three gaps set out in the NHS Five Year Forward View, the CCGs are now faced with considerable financial challenges and a need to reduce system costs alongside preparing our organisations to work in more integrated and collaborative ways that ensure there is a sustainable health and care system to improve outcomes of our diverse and growing population.

Strategic Drivers

The NHS Long Term Plan published in January 2019 sets out a refreshed vision for the future of NHS services, building on the Five Year Forward View. The plan confirms the need to streamline commissioning arrangements via a single CCG for each Integrated Care System (ICS) rather than the existing CCGs that we currently have across North Central London. This will enable a single set of commissioning decisions at system level that includes the development of local Integrated Care Partnerships (ICPs) which would be underpinned by Primary Care Networks (PCN).

In view of the above, every system will need streamlined commissioning arrangements to enable a single aligned strategic commissioning direction that will support a new system accountability framework and provide a consistent and comparable set of performance measures.

8888



The Plan confirms existing clinical priorities and makes a number of commitments in that the NHS will:

Do things differently through a new service model

Take more action of prevention and health inequalities

Improve care quality and outcomes for major conditions

Ensure the NHS staff get the backing they need

Make better use of data and digital technology

Ensure we get the most out of tax payers’ investment in the NHS – including that CCGs will deliver a 20% management cost reduction

In line with the NHS Long Term Plan, over the past 6 months, across NCL, there has been a co-ordinated programme of events (The Inter-great events ) exploring potential future arrangements for integrated health and care, at borough level and across the five boroughs. This has identified a number of opportunities to increase the level of collaborative working, to work differently, to strengthen front-line support to residents and a population-wide approach to health and wellbeing.

Alignment of Commissioning and Operational Delivery

The key drivers for change that have been identified to support the alignment of our Commissioning arrangements and operational delivery have been identified as:

The NHS Long Term Plan sets out that there will be one CCG per Integrated Care System (and therefore one for North Central London)

Current governance and decision points are duplicative and can slow down the impact we can have for residents

We need to move away from transactional processes to delivering transformational change

We need to dedicate more time and focus to borough-based integration to increase our focus on communities and prevention

We need to improve how we plan services based on population health in order to maximise the impact we can have

Benefits of Merging

There are different types of benefit that will occur from merging our CCGs. These include:

Economic Benefit - Financial Improvement, releasing cash, increased income, better use of funds;

Effectiveness Benefits - Doing things better or to a higher standard;

Efficiency Benefits - Doing more for the same or the same for less;

People Benefits – A benefit that although it has an economic, efficiency or effectiveness reason has a direct benefit to our people;

System Benefit - A benefit that although it has an economic, efficiency or effectiveness reason has a direct benefit on our systems.

These will benefit - either directly or indirectly - patients and local people, GPs and other clinicians, health and care partners and many others. Some benefits will be achieved through the bringing together of the existing organisations in the short term, whilst other benefits will result from the support that a single CCG can provide to the development of an Integrated Care System for North Central London over time.

8989



Moving to the new operating model and the merger of the CCGs to a single CCG will support the achievement of the 20% management cost reduction set out for CCGs in the Long Term Plan.

To realise the full scale of the benefits of merger, we have begun to map out some of these benefits as part of our Benefits Realisation Plan for Merger. Below is a summary of some of the benefits that will come from merging, and how they will be delivered over time:

Benefits Management Approach

To deliver these we will be following a benefits management approach within the change programmes.

We are currently in the identification and quantification stage – which is being considered by the finance working group with representatives from the CCGs’ finance teams.

Initial focus for quantification is on those benefits relating to greater efficiency where changes need to be in place for 2020. Work on longer term improvements to outcomes will follow this work.

9090



Our History of Joint Working

Collaboration across the North Central London, both externally with partners and internally across the CCGs, has increased at significant pace over the past two and half years – following on from the appointment in 2017 of a single Accountable Officer and Chief Finance Officer for the NCL CCGs.

Collaboration with Partners

The geographic boundary for a single North Central London CCG will have strong alignment with key partners and partner organisations within the current STP footprint:

General Practices and GP Federations

Patients and the Public

Healthwatch

NHS Provider Trusts

Local Authorities and Public Health

This in-turn will provide a natural path to all key partners working together with an Integrated Care System for NCL and therefore fulfill the requirement of the NHS Long Term Plan of a single strategic commissioner within the footprint.

Whilst, on occasion, the existing NCL CCGs also work with other CCGs – this will not be impeded by moving to a single CCG:

The proposed operating model will enable local teams to work with other ‘cross-border’ CCGs. Similarly, the model will also support local working with other local partners.

The current CCG-led consultation on the proposed redevelopment of Moorfields Eye Hospital has required working a number of other CCGs outside of North Central London. The links to NCL CCGs has been coordinated through the NCL Joint Commissioning Committee (see below) and therefore is already being managed in a collaborative manner.

9191



Collaboration across CCGs - Governance

Since 2017 the NCL CCGs have operated an increasing number of collaborative governance arrangements – ensuring both consistency and efficiency across a number of key committees:

Joint Commissioning Committee – including, for example, acute commissioning, learning disability contracting associated with the Transforming Care programme, integrated urgent care (including 111/ GP Out-of-Hours services) and any specialised services not commissioned by NHS England

Primary Care Commissioning Committee in Common

Audit Committee in Common

Independent Funding Requests Panel

Specific examples of commissioning that has benefitted from the single NCL committee approach are:

The clinical delivery model for the Adult Elective Orthopaedic Services which will deliver improved quality of care and outcomes through increased provider collaboration across base hospitals and elective centres;

NCL integrated Out-of-Hours service which brings together NHS111 and GP Out-of-Hours to deliver a consistent and equitable quality of service across the STP footprint while also delivering economies of scale, such as enabling CCGs to monitor a single contract.

The appetite for, and benefits of, collaboration across NCL can be further illustrated through the joint commissioning of the Health Information Exchange project – which will create a single, comprehensive view of an individual’s health record, available to health professionals at the point of care.

A single CCG will provide a strong platform to enable further efficient and effective commissioning of consistent healthcare service to all patients across North Central London.

Collaboration across CCGs – single management structure

Also since 2017, the CCGs have benefitted from a single Senior Management Team including the single Accountable Officer, Chief Finance Officer and a number of Director-levels posts undertaking roles on behalf of all NCL CCGs:

Director of Strategy

Director of Performance, Planning and Primary Care

Director of Acute Commissioning

Director of Corporate Services

Taking Corporate Services as an example, a single NCL directorate has now been in place for over a year - delivering a range of joined-up corporate functions to each CCG (Governance, Risk, Secretariat, IG, HR & OD and Communications & Engagement). This approach has delivered strong consistency in service delivery and realised both financial and process efficiencies. Under a merged CCG for North Central London – we will be in a strong position to implement a similar model and realise similar benefits for other areas of the operating structure.

Recently, a Director of Quality position has been added to the NCL Senior Management Team – again to provide cross-CCG consistency in Quality and Safety work, also complementing the existing network of Directors of Quality working together across NCL.

Communicating and Engaging on Our Merger Plans

Effective communications and engagement have been central to the development of our plans for merging the existing CCGs across North Central London. This has taken place in conjunction and

9292



alignment with communications and engagement on the Long Term Plan and our local plans for developing an Integrated Care System and borough based Integrated Care Partnerships. This has allowed us to demonstrate the relationship between the different developments whilst also ensuring that core stakeholders and messages specific to the CCG merger are clearly communicated.

Communications and engagement principles

Through our Engagement Advisory Board we have developed the following principles for how we will engage around the Long Term Plan, London Vision, and the NCL Change Programmes:

The NCL CCG communications and engagement plan will be updated on an iterative basis, aligned with the key phases of the change programme plans. Under this, local CCG communications and engagement teams will work with their leadership to develop CCG-specific communications and engagement plans

Regular updates will be provided to all key audiences and the main stakeholders for the change programme will be fully engaged and, where appropriate, formally consulted

To ensure clarity, NCL change programme messaging and core communications materials will be produced centrally and updated on a rolling basis – circulated to local CCG teams to be appropriately tailored and used locally

Insights from communications and engagement activity undertaken by all partner organisations will be collated to inform the change programme on an ongoing basis

An appropriate HR process will be set out in an HR Transition Plan – which will be closely aligned with the communications and engagement plan to avoid duplication or confusion

Communications and engagement on the merger

Robust engagement has been undertaken at both borough and North Central Level to support our application to merge. Key stakeholders have confirmed their support for the CCGs moving to a streamlined NCL health commissioning function and for our ambitions to assist the development of an NCL Integrated Care System. A summary of our full communications and engagement activity, and the feedback received to date, is included in section 3 of this document.

Support for Merger

The existing CCG Governing Bodies in North Central London agreed to pursue a merger to a single CCG following seminars in May 2019. Since that decision extensive work has been undertaken, both within the organisations and with our partners, to ensure full support for the merger and consensus on the case for change.

Support from CCG Governing Bodies

The CCGs in North Central London already operate under a single Senior Management Team (SMT) structure, including a single Accountable Officer and Chief Finance Officer. The programme to develop the merger has been led by the SMT.

The NCL CCGs’ Assurance and Oversight Group (AOG) was established in July 2019 to oversee progress towards merger and to ensure that key issues that may impact on support for the merger from Governing Body members are addressed in a satisfactory way. This group consists of the chairs from each CCG and a nominated lay member, plus members of SMT and the programme team.

9393



So far a number of priority areas for assurance have arisen from these discussions and we have sought to resolve these through the development of documentation to support the merger that provides the required assurances and safeguards to address the core concerns. The key points have been captured in appendices to this paper, including:

The financial principles of merger, including the treatment of historical deficits and surpluses, and the approach to budget setting at a borough level (see Appendix B – Our Financial Strategy & Arrangements for Delegated Decision-Making);

The future approach to Patient and Public Engagement (PPE) in the new single CCG, including how we will ensure no dilution of the resident voice in decision making (see Appendix A – Our Approach to Patient and Public Engagement);

The governance structures and Governing Body make-up in the new single CCG (see Appendix B, C and related content above).

Prior to submission of our formal application to merge to NHSE England full confirmation of Governing Body support will need to be confirmed and documented.

Support from our partners

As set out in our communications and engagement plan we have conducted extensive engagement both at borough and NCL level throughout the last few months to ensure that key partners are briefed on and supportive of our proposal to merge. This includes listening to and responding to any concerns raised.

The programme to develop and implement the merger of the CCGs has been run as part of the broader NCL Change Programme approach, which includes the programme to support the development of an Integrated Care System and borough-based Integrated Care Partnerships. This has ensured that there is consistency between the development of the future operating model for a single NCL CCG and the emerging principles for a working as a single Integrated Care System. For example, the cross-partner ICS Design Group has agreed the levels at which each function will operate and be owned within an Integrated Care System. This has in turn been used to inform and guide the development of the operating model for the single CCG, and which commissioning functions would need to sit at which level.

This alignment has helped ensured that partners are bought into and supportive of the merger process. As evidence of this, letters of support received to-date from partners are included at Appendix E.

Intervention and Delegated Authority

Intervention

Currently none of the existing NCL CCGs are under directions from NHS England.

Delegated Authority

The North Central London CCGs (NCL CCGs) became responsible for fully delegated primary care commissioning in 2017. This built on the experience, skills and knowledge gained from being joint commissioners with NHS England from October 2015.

The NCL CCGs have robust and effective arrangements in place for delegated primary care commissioning. This includes the NCL Primary Care Commissioning Committee in Common between the CCGs to exercise oversight and decision making, a central NCL wide team for GP core contracting from NHS England who are now CCG employees, a central director with responsibility for delegated primary care commissioning who is a member of the NCL CCGs’ central Senior Management Team,

9494



reports directly to the Accountable Officer and works with the primary care teams in each of the CCGs. The CCGs’ internal auditors recently conducted an audit on commissioning and procurement of services and found that there was ‘reasonable assurance.

The above arrangements would smoothly transition to a new single CCG with a single Primary Care Commissioning Committee providing oversight of the arrangements and exercising decision making in accordance with NHS England statutory guidance.

2. Our Approach to Delivering the Merger

The North Central London Change Programmes, including the CCG merger programme, are led by the NCL CCGs Senior Management Team. SROs for each programme have been appointed from within the SMT and support for each programme and workstream has been identified from within CCG resources. The below diagram provides an overview of the structure of the programmes and the staffing resources allocated to the management and delivery of each programme. In addition, support is being drawn from the relevant CCG and STP leads within the system to develop and deliver the specialist content of each programme.

The below timeline outlines the key milestones across the North Central London Change Programmes, and how they align. This includes the key merger timetable but aims to set this is in the context of wider development across the system to implement the Long Term Plan and develop Integrated Care.

9595



PMO

The CCG Merger process is supported by a centralised Programme Management Office, working

across three broad change programmes given their interdependencies:

These are:

Management Cost Reduction/Service redesign;

The CCG merger;

Establishing an Integrated Care System and borough-based Integrated Care Partnerships.

Managing the programmes together allows to ensure that we effectively manage the

interdependencies between them. For example, ensuring that the design of the single CCG operating

model takes account of how the whole system needs to work differently in the future, and explicitly

supports and enables the development of integrated care partnerships at a borough level. Aligning the

timelines for the programmes is also expected to support staff to work in new ways and be part of

creating the new integrated system, solving some of the issues of fragmentation across organisations

that mean our residents do not always get the very best care possible.

A shared programme office supports both the day-to-day activities leading to the merger as well as

the assurance and senior oversight functions into the process. The PMO is responsible for tracking

deliverables, ensuring all assurance criteria are met, monitoring risks, issues and dependencies

between the workstreams, and ensuring reporting and information flows.

9696



SRO and Change Management Team

The key personnel responsible for the day-to-day deliverables and overall assurance are:

Role Key Tasks Who

NCL Change

Programmes

Sponsor

• Oversight of overall programme Helen Pettersen

CCG COOs • Leading the development of borough based Integrated Care Partnerships

• Provide input as require via the Transition Board to manage risks

• Ensuring timely briefing of staff

CCG COOs

Programme SRO • Ensuring that the workstreams plan is realistic and includes the correct list of products/deliverables with the right programme management in place.

• Ensuring that the deliverable owner has the necessary skills, resources and experience required to deliver the change.

• Assuring the programme’s engagement approach, including leading high-level engagement activities as required (for example with Governing Body members, staff, LA Partners and NHSE.)

Ian Porter,

Michelle Chadwick,

Will Huxter

Organisational

Development lead

• Provide specialist input, advice and lead the organisational development elements across the workstreams.

Michelle Chadwick

NCL Change

Programmes

Director

• Ensuring progress to plan – and any governance deadlines – across the programme as a whole.

• Ownership of list of deliverables as defined by SROs. • Oversight and management of programme office and

programme managers. • Ensuring that all members of the project team have

clear responsibilities. • Overall responsibility for managing risks and issues

associated with the programme.

Richard Dale

Head of

Communications

and Engagement

• Responsible for the development and implementation of a robust communications and engagement strategy is in place

• Manages key programme communications and engagement with staff, local stakeholders and the public working with CCG communisations teams

• Provides specialist input and advice to SROs and deliverable owners

Fran McNeil

Delivery lead • Develop detailed solutions and leading analysis and design to complete deliverables as defined by SRO.

• Supported by programme management office and programme leads and sub groups as required

As required based

on skills required

Programme Governance

The following distinct groups oversee change management governance:

The Transition Working Group is chaired by the Programme Director and includes the Head of the Programme Management Office and SROs from all the work streams. The group meets weekly to review

9797



progress against plans, track delivery and detailed work, identify and mitigate key risks and determine next steps. The group is supported by task and finish groups to enable specific deliverables as and when required.

The CCG Transition Board consists of Helen Pettersen, NCL CCGs’ AO; COOs of all CCGs; the Chief Finance Officer, the other members of the NCL CCGs’ Senior Management Team, the Programme Director and the SROs of all workstreams - and reviews the programme highlights and key risks. The group provides overall leadership to the programme and helps ensure that the programme milestones are met and that changes are implementable across NCL (and within CCGs/Boroughs) without disrupting operations. The group meets once a week.

The Assurance and Oversight Group consists of the Chairs of each NCL CCG, a lay member from each NCL CCG, the Accountable Officer (& sponsor of Change Programme), the Chief Finance Officer, Director of Corporate Services for NCL CCGs (& SRO for CCG Merger), HR Transition Director (Interim) (& SRO for Management Cost reductions), Programme Director for NCL Change Programme and Head of Communications & Engagement (for NCL corporate activity). The group meets monthly and its role is to:

Take a strategic overview of the development and delivery of the change programme;

Review key proposals and plans and progress in delivering the related key milestones – providing steer and feedback to the implementation groups / teams;

Provide a Clinical Member and Lay Member view on the emerging proposals, and so provide assurance to other Governing Body members that these perspectives have been taken into account in the planning and delivery work;

Take an overview of the key risks and issues associated with the delivery of the programme – also helping to identify any new risks or issues arising (including through group members’ discussions with other Governing Body members or key stakeholders);

Be assured that robust stakeholder engagement is being undertaken and that key feedback is being reflected in ongoing planning and implementation work;

Help provide a strategic view on external and internal communications, and organisational development priorities in relation to the programme;

Be assured that all mandatory requirements associated with the programme (e.g. CCG merger application process) are being met.

9898



Summary of current risk register

Below is a summary of the key risks from the programme risk register.

9999



3. Our Merger Communications and Engagement Plan

A robust programme of engagement and communications on the North Central London Clinical Commissioning Groups (NCL CCGs) proposal to merge was undertaken between May – September 2019, meeting the requirements set out in the published NHS England guidance. The following paper provides a summary of the strategic approach, activity undertaken and a thematic summary of the feedback received. Engagement will continue through 2019-20.

The following principles for merger engagement were agreed:

The NCL CCG communications and engagement plan will be updated on an iterative basis, aligned with the key phases of the change programme plans. Under this, local CCG C&E teams will work with their leadership to develop CCG-specific engagement plans

Regular updates will be provided to all agreed key audiences and the main stakeholders for the change programme will be fully engaged

To ensure clarity, NCL change programme messaging and core communications materials will be produced centrally and updated on a rolling basis

Insights from communications and engagement activity undertaken by all partner organisations will be collated to inform the change programme on an ongoing basis

An appropriate HR process will be set out in an HR Transition Plan – which will be closely aligned with the communications and engagement plan to avoid duplication or confusion

Borough- and NCL-level engagement

The overarching NCL CCG communications and engagement plan outlined the required activity to be delivered by each CCG for their boroughs across June to September. Local CCG leaders were supported by their Head of Communications and Engagement to produce detailed local engagement plans, aligned to the NCL plan. It was agreed that wherever possible existing CCG channels and meetings should be utilised.

In addition to CCG borough-level engagement, members of the NCL CCG SMT also undertook engagement activity with some key audiences at an NCL level. Specifically, it was agreed that

NCL Joint Health Overview and Scrutiny Committee (JHOSC) would be engaged, rather than the five local OSCs. Engagement has also been undertaken with the borough LMCs at an NCL level.

Across May – September, robust engagement with the agreed key audiences was undertaken to inform, and evidence support, for the CCG’s application to merge. Multiple opportunities were identified for discussions, per audience, through a variety of methods. These included meetings, briefing events, calls, letters, newsletters, webinars, website and intranet information and published Frequently Asked Questions. Further detail in set out in Table 2, below.

Summary of engagement activity undertaken

The NCL CCG SMT Transition Board, and the CCG Assurance and Oversight Group, are confident that robust engagement has been undertaken to inform our merger planning and that no issues arose regarding the engagement approach we have taken that would impact our application to merge. As well as engagement activity specifically focused on the CCG merger, NCL and borough meetings focused on developing integrated care systems – including information around the future direction of travel for commissioning (in NCL, with one merged CCG).

100100



Key themes from stakeholders is set out below – which is supported by the following tables:

Table 1 - illustrates, per audience, whether engagement activity was undertaken by individual CCGs, or at an NCL-level, or both;

Table 2 – summarises the engagement activity undertaken with stakeholders;

Table 3 - provides a summary of feedback from each stakeholder category.

Table 1 – Engagement Activity

NCL Barnet Camden Enfield Haringey Islington

Governing Bodies

Member practices

CCG staff

Unions / staff side

PPE Committees

Council Chief Executives*

Council Leaders*

Council Leads for Health*

Directors of Adult Social Care

Trust Chief Executives

HWBB Chairs*

LMCs

Healthwatch

J/HOSC Chairs*

*In some boroughs these stakeholders were engaged via the Health and Wellbeing Board.

101101



Table 2 - Summary of NCL CCGs’ engagement approach

Audience Engagement activity summary

Governing Bodies

CCG Governing Body members were engaged in the merger planning programme through a number of seminars specifically focused on the merger, as well as other existing Governing Body fora.

Governing Body members also received email briefings in addition to the updates of merger planning included in fortnightly staff newsletter.

Chairs and Lay Members with responsibility for PPE participated in the NCL CCG Assurance and Oversight Group, assuring the merger plan and process.

Lay Members with responsibility for PPE also participated in the NCL Engagement Oversight Group, where the NCL change programme (including merger) was discussed.

Member practices

Merger plans were presented and discussed at existing member practice meetings. Practices received the commissioning meeting papers via email/websites.

Practices that were not engaged at commissioning meetings where merger planning was discussed were contacted, offering the opportunity to discuss this directly with the CCG.

Information on integrated care / the NCL change programme was shared on CCG GP websites, and included in GP bulletins. In one borough, a webcast was held with Primary Care Network leads.

Federations were engaged via borough Integrated Care Partnership meetings and in some boroughs, direct discussions with the CCGs

Unions / staff side reps

Joint Partnership Group meeting held with management and local/regional

representatives in August 2019 to share the approach of managing the HR transition

programme in line with the HR Transition Framework.

Monthly Joint Partnership Group meetings scheduled with management and

local/regional trade union representatives to ensure staff side are kept up to date on

progress.

Summary of communications to staff and support to be available for staff on the

transition programme shared with Regional Representatives from recognised trade

unions

Pre-engagement and engagement with staff side as part of formal consultation

processes during each wave.

PPE Committees

Patient and public engagement committees/groups was engaged through existing meetings, where updates on the NCL change programme were brought for discussion

Council officers and political leaders

The NCL CCGs’ senior leadership, through existing meetings, ensured that the CCG merger plans were shared and discussed with Council Chief Executives, Council Leaders, Directors of Adult Social Care and Councillors with a health portfolio, and in some boroughs, Public Health colleagues

Senior council representatives have participated in regular borough level meetings to discuss development of borough Integrated Care Partnerships, within which CCG merger has been discussed.

Providers The NCL CCGs’ senior leadership, through existing meetings, ensured that the CCG merger plans were shared and discussed with Trust Chief Executives

Trust leaders were represented at the NCL Integrated Care System Design Group, meeting monthly from July – September, to shape plans for integrated care. The requirements of a strategic NCL commissioning function to support the development of ICS and borough ICPs was considered within design planning.

102102



Acute Trust representatives and other Provider leaders have participated in regular borough level meetings to discuss development of borough Integrated Care Partnerships, within which CCG merger information has been shared.

LMCs NCL SMT members have met with LMC representatives at an NCL level. In some boroughs, LMC senior representatives have also been engaged via meetings.

Health and Wellbeing Board Chairs

Per borough, Health and Wellbeing Board Chairs have been engaged via meetings, conversations and/or sharing of merger planning information via email, through the engagement period.

Health and Wellbeing Board representatives have also participated in borough level meetings on the development of borough Integrated Care Partnerships, including discussion on commissioning at an NCL, borough and neighbourhood level.

Health Overview and Scrutiny Committees

It was agreed that formal engagement with HOSCs would be undertaken at an NCL level with JHOSC. Information on merger plans was brought to JHOSC in March, and an update is scheduled for the September JHOSC. Per borough, information has been shared with HOSC Chairs, as part of discussions on local and NCL plans for the development of integrated care.

Healthwatch Per borough, a variety of different methods have been used to engage Healthwatch organisations, including briefing meetings with COOs/Chairs and participation as members of PPE Committees (where merger planning was discussed.

The five Healthwatch organisations also participate in the NCL Engagement & Advisory Board, where the NCL change programme (including merger) has been discussed.

Staff NCL CCG staff were regularly engaged through the merger planning process through updates at fortnightly staff briefings, fortnightly staff newsletters, and in some boroughs, away days.

Staff were able to submit questions via the five intranets, their line manager, to HR or directly to the merger programme team inbox.

Senior staff participated in two Wider Leadership Meetings focused on the change programme, including the merger.

In some CCGs, staff briefing sessions (lunch and learns) were run to provide staff on key topics related to the NCL change programme (e.g. integrated care partnerships, primary care networks).

Themes of Stakeholder Engagement Feedback

The main themes of the feedback received to date through the CCG’s collective stakeholder engagement regarding the proposals to merge have been summarised in this section.

Overall, across the five boroughs, our engagement identified that there is support for the direction of travel, set out in national policy, to streamline commissioning arrangements to enable a single set of commissioning decisions at system level – in NCL, by proposing to form a single CCG.

Stakeholders recognised the benefits that merging could deliver around reducing health inequalities, making greater collective progress on improving health outcomes, streamlining commissioning decision making, reducing duplication and reducing transactional costs, and enabling us to deliver the required 20% reduction in manage costs from April 2020. The proposal to merge was often discussed in the context of creating commissioning functions that align with, and support, the establishment of Integrated Care System and borough ICPs – on which positive progress is being made in NCL.

103103



Our engagement was undertaken in parallel with the CCG’s merger planning. As such, there was recognition that detailed information on some key areas is currently in development. There was interest among stakeholder groups to continue to receive updates, including detail on the following when available: what will ‘happen’ at what levels, the future clinical leadership model for the CCG (and integrated care system), how strong borough commissioning relationships at a borough level will be maintained (e.g. with member practices), and how the support currently offered by CCGs locally would be maintained. Feedback captured from engagement has, and will continue to inform our planning.

Some themes around potential concerns have been identified through our engagement activity. These included around successfully delivering the merger a short timeframe (if working towards April 2020), some financial issues related to merger of CCG budgets and protecting levels of local investment, and maintaining local commissioning accountability. There was recognition that any significant transition period is unsettling and may impact CCG staff retention and morale, and that merging sooner would avoid an extended period of uncertainty.

Table 3 - Audience-specific feedback summary

Members Interest in future GP clinical leadership model

Keen to understand role of GP federation and neighbourhoods in new system

Queries / interest in how budget allocations will work under a single CCG, and GP funding

Interest in protecting quality and maintaining safety

Queries how different population health profiles per borough would be managed under a single CCG

Concerned with maintaining local commissioning relationship and support (e.g. GP IT, GP websites, links with CCG primary care teams)

An opportunity for standardised training across the NCL

Keen local CCG knowledge and relationships are retained

Interest in future governance arrangements, including clinical representation on Governing Body by borough

Council / Public Health / LMC

Councillors keen to understand role of Health and Wellbeing Boards (HWBBs) in new structures

HWBBs, Councillors, and LA colleagues want to understand how local funding and current services will be preserved

Public Health colleagues keen to understand future levels of services centrally and with boroughs

Keen to be kept informed of changes as they develop

LMC welcomed opportunity to discuss the change programme in depth and want to be kept informed

Interest in what will remain commissioned locally and retaining local commissioning expertise

Healthwatch Healthwatch want to see a transparent process continuing, receive regular updates and to understand how they can be involved (in the wider NCL change programme)

Keen to receive further information, when available, on:

104104



New governance structures

How changes will impact residents and the local population

Impact of CCG management cost reduction on patients and residents

How the local voice will continue to be heard in the single CCG structure / future PPE model

Staff High levels of interest in the HR transition process and merger process

Key themes from staff questions include: the future operating model, changing roles and functions, redundancies, future office locations

Engagement Next Steps

The NCL CCGs will continue to maintain an open dialogue with all our key stakeholders on the merger proposals, and are committed to sharing further detail on all the key elements of our merger plans as these become available. Key decisions will be communicated promptly.

Communications materials and messages will be regularly updated and published/disseminated through all our available channels, to ensure the latest information is easily accessible.

The feedback generated through our ongoing engagement will continue to be captured and analysed on a rolling basis, and brought to CCG Governing Bodies, NCL CCG Senior Management Team and other key leadership fora, to inform the CCGs’ merger plans.

If a decision is made to proceed with a merger from April 2020, detailed planning will be undertaken to ensure that we have robust communications and engagement processes in place for the newly merged CCG for 2020-2021, including on our NCL CCG patient and public engagement strategy.

105105

NCL CCGs

Merger Proposal v1.0

P a g e | 34

Appendix A: Our Approach to Patient and Public

Engagement

Patient and public involvement is a key role for the CCG.

The Health & Social Care Act 2012 sets out that CCGs must make arrangements to secure that individuals to whom the services are being or may be provided are involved in:

a) the planning of the commissioning arrangements;

b) the development and consideration of proposals for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them

c) decisions affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.

Through the NHS England Improvement and Assessment Framework (IAF), CCGs are assessed on how statutory duties are met in relation to patient and community engagement. Our aspiration for an NCL CCG should be to achieve an ‘Outstanding’ rating for the patient and community engagement indicator by 2020/21.

Across NCL, we face a wide range of health inequalities - and reducing these inequalities will continue to be a key priority for a single NCL CCG and local borough partnerships. Our approach to patient and community engagement should also therefore encompass and consider the CCG’s responsibilities around equality, diversity and inclusion.

This paper sets out how these principles will be delivered through the new single CCG for North Central London. This will form the content for our application for merger.

Partnership Working - NCL Engagement & Advisory Board

In the context of a changing landscape for the commissioning and delivery of healthcare services – it will be important for engagement activity to be planned with key partners.

The NCL Engagement & Advisory Board (membership includes CCG lay members, Healthwatch, Voluntary sector, Councillors and CCG communications and engagement colleagues) that has recently been established has developed a set of principles that will guide partnership-based engagement approaches on the NCL Change Programmes across North Central London. These principles are to:

identify, understand, listen to and respond to our stakeholders;

put residents and patients at the heart of our work – by making sure they are involved early and represented in discussions;

ensure residents and communities have opportunities to influence our work;

engage with residents experiencing the greatest health inequalities;

build and protect local relationships with residents, communities and community groups;

be clear about why we are engaging with patients and the public;

listen and respond to feedback, being honest about what we can and can’t do;

be clear about the impact that resident engagement has made;

106106

NCL CCGs


P a g e | 35

involve voluntary, community and representative groups as partners and enablers;

work with our health and care partners rather than creating additional systems, processes and channels;

be open and transparent by providing accessible, clear, meaningful and timely communications; and

ensure equality impact assessments are robust and are carried out to inform our work.

Foundations for Patient, Public Engagement & Involvement in a single NCL CCG

Specifically focusing on a potential move to a single NCL CCG, work has been undertaken with the CCG lay members, clinical leads for engagement, and CCG communications and engagement colleagues to consider a proposed approach for the new CCG. The following statements outline how the proposed new PPE function of the CCG will work:

A commitment to patient and community engagement, reducing health inequalities and supporting people to manage and improve their health and wellbeing should be very clear throughout the NCL CCG’s vision and values. The CCG’s governance arrangements should also be very clear and transparent for the public.

The CCG move to a larger geographical footprint will not restrict the ability to engage with and be influenced by the needs of local communities within boroughs.

The CCG will fulfil its statutory duties.

The CCG will use the IAF domains to guide patient and community engagement – maximising best practice currently in place across the existing CCGs.

Engagement activity will be needed at NCL and borough levels to support the CCG and borough partnerships with this work. Accountability and opportunities to influence should be 2-way between the NCL CCG and the boroughs.

The proposed approach will need to be flexible as borough partnerships and the NCL integrated care system develop.

Working in partnership, we should strive to widen the reach of our engagement activity – ensuring the focus remains on improving health outcomes and reducing health inequalities through the CCG’s commissioning activity.

Proposed approach

Under a single CCG – there will need to be a balance between the work undertaken across NCL and the work undertaken at a local, community-based level. Examples include:

NCL wide activity:

To develop and oversee delivery of NCL engagement/involvement strategy

To lead and manage engagement work on pan-NCL programmes, commissioning intentions and strategic plans

To work with local borough teams - utilising local approaches, relationships, knowledge

To support stakeholder engagement at an NCL-wide, strategic level e.g. working with JHOSC

Borough activity:

To support specific borough-level engagement work

107107

NCL CCGs


P a g e | 36

To support borough partnerships – which will provide excellent opportunities to work closely with local authority colleagues, Health and Wellbeing Boards and providers

To support primary care networks to meet their engagement requirements (delivered locally, but with as much consistency as possible across NCL).

Within the CCG, planning and delivery of communications and engagement activity will be well-coordinated between the NCL- and borough-level, and NCL PPE will be reflected within local PPE activity. This will ensure there is no duplication of CCG effort and that the CCG does not overburden partners will poorly coordinated requests to work together. Intelligence gathered through CCG engagement work across NCL will be triangulated to form an in-depth picture of our residents’ views and experiences. We will also ensure that we can show ‘You Said - We Did - It Made a Difference”.

CCG PPE activity will also be well coordinated, and will support, PPE work planned at an NCL level by the Integrated Care System and at a borough level by the Integrated Care Partnerships. We will support ensuring there is clarity for voluntary and community sector organisations on where there involvement would be most effective, and where there are opportunities for organisations (e.g. the five Healthwatches) to link up and be involved.

Proposed Governance arrangements

Recognising the importance of the CCG’s patient and public responsibilities and activity, it is proposed to establish a single NCL Committee for Engagement & Equalities – that reports directly into the NCL CCG governing body (ensuring that patient and community engagement is on equal footing with the other main CCG committees).

Committee membership should include NCL CCG lay members with portfolios for equalities and engagement, relevant clinical leads, representation from Healthwatch and the voluntary and community sector, patient representatives, local authorities, representatives from borough partnership teams, and other officers/directors. [To note, the current NCL Engagement Advisory Board would be stood down post-CCG merger].

The role of the CCG’s Committee would include:

Assuring the CCG that effective engagement and involvement is taking place across NCL and throughout the CCG and that the CCG is meeting its statutory duties and the IAF criteria

Having oversight of the CCG’s engagement/involvement strategy, action plan and activity

Ensuring that meaningful engagement is undertaken to help inform commissioning and commissioning decisions, and that the CCG is really acting on the feedback heard from local communities

Supporting and helping to ensure co-ordination and consistency of local engagement activity undertaken through borough-based partnership working

Sharing good practice and successes in local engagement work with other parts of NCL;

Being an advocate for ensuring the NCL CCG engagement and involvement approach is best practice, not overly bureaucratic and enables us to demonstrate the value and benefits to residents

Having oversight of the CCG’s equality, diversity and inclusion strategy, action plan and activity

Ensuring the CCG is successfully holding providers to account for their engagement and equalities duties

Additionally, we will seek opportunities for patient representatives sitting on the PPE Committee to also sit on relevant other NCL CCG committees.

108108

NCL CCGs


P a g e | 37

Working at a local, community level

Engagement structures and approaches will need to be discussed and developed locally by the borough partnerships, building on the existing structures, approaches and local knowledge that exist across partners.

However, it is recognised that it will be helpful to have a borough-level partnership engagement group/committee which will have a dual reporting role into the NCL CCG committee and to the borough partnership boards.

The approach will need to be flexible as the borough partnerships develop over time.

109109

NCL CCGs


P a g e | 38

Appendix B: Our Financial Strategy & Arrangements for

Delegated Decision-Making

Approach to in year budget setting and transition to new ways of working

Introduction and context

North Central London CCGs are proposing to merge to a single commissioning body in April 2020. This will mean adopting new governance structures across NCL with an aim of reducing unnecessary and duplicative decision-making.

As part of the process of moving to a single statutory organisation, the Governing Bodies for the existing CCGs in North Central London have asked for the development of financial principles to provide assurance on how the new single CCG will take financial decisions. In particular assurance is sought in relation to decisions on in year budget setting and the mechanisms for ensuring subsidiary and effective decision making in the new organisation.

The financial principles will need to:

a) Comply with national guidance and CCGs’ statutory duties, b) Support delivery of the NHS Long Term plan c) Support delivery of the NCL Medium Term Financial Strategy, which is currently in development.

This paper sets out a proposed approach to this, including how the principles may translate into changes in decision making and budget setting in the future, based on current known information.

Context: New operating model

The future model looks to centralise certain functions under members of the executive team where there is clear benefit to working across the larger footprint to maximise the impact for local residents. This will include, for example, where working at scale will allow best use of resources, will deliver greater efficiencies for the population, or will ensure a more coordinated approach across the system. These centralised commissioning functions will need to evolve over time into strategic functions, making use of new mechanisms to enable the system and Integrated Care Partnerships to deliver against outcomes which are set over longer periods of time.

Under the new executive team, the CCG will also have clear borough facing functions with senior leaders based at borough level. The primary role of these roles will be to work with partners to facilitate the development of borough based partnerships (ICPs). This will mean working together with primary care, community, mental health, social care and voluntary sector partners to configure their services around individuals rather than organisations.

Over time, there will be delegation of responsibilities to the local Integrated Care Partnerships. The development of the partnerships will be important building blocks around which the NCL Integrated Care System will be built.

Benefits of the merger: reducing duplication and increasing effectiveness of decision-making

One of the benefits of merging is to move to a more effective decision making process that reduces duplication.

The proposed new committee structure is set out in the following diagram:

110110

NCL CCGs


P a g e | 39

In this model, single NCL committees will support the longer term planning and streamlined decision making across NCL. For example, the Finance Committee will set out the coming year’s budget and financial strategy which will be guided by the financial principles proposed further below in this document.

Borough based decision-making

In the proposed governance structure for the NCL CCG, it is not feasible, nor desirable, for all financial decisions to be taken at an NCL level and a key feature of the model includes the ability to commission local and, in-particular, community-based health care services at borough level. A key principle for the CCG will be to deliver functions at the most appropriate level to maximise commissioning outcomes and the associated benefits for our patients.

Therefore, to support the principle of subsidiarity, deliver the benefits of effective delegated decision making and ensure alignment with integrated care developments at borough level, it is proposed that relevant decision-making arrangements and thresholds are set at a borough-level. This will delegate responsibility, authority and budget related to Primary / community / out of hospital services to borough based groups. To ensure the ongoing provision of strong clinical leadership, it will be important these arrangements involve the elected clinical representatives from the relevant borough area.

These local arrangements could take the form of a borough-based group or formal sub-committee of the NCL Strategic & Commissioning Committee – helping to ensure a consistent and coherent approach across the sector. Alternatively, borough areas will have the option (through the Scheme of Delegation) to delegate specific decisions to, for example, the respective elected GPs and Managing Director.

Where a borough-based group or sub-committee is established – it is proposed that the membership, as a minimum includes:

The two elected clinical representatives from the borough area;

An NCL lay member;

The borough-based Managing Director.

111111

NCL CCGs


P a g e | 40

It is also proposed that the Chair is one of the two elected clinical representatives and, where required, the Chair will have the casting vote.

It will be important for the groups or sub-committees to be supported by the Executive Director of Strategy and Executive Director of Strategic Commissioning - to ensure congruence of borough and NCL wide integrated care system developments. The groups will also need to draw on senior support from the NCL Finance Directorate.

The members of the group or sub-committee will work as appropriate with their local teams, relevant clinical leads (non-GB) and take account of the work to develop borough Integrated Care Partnerships (ICPs) - to make decisions in line with local needs. Typically this may include, but not limited to, the group or sub-committee working with colleagues from respective local authorities and patient representatives.

The level of delegation, remit and membership of the borough-based groups or sub-committees will need further development over the coming weeks to ensure robust levels of accountability and transparency. However, initially it is envisaged that the primary function of these groups would be to oversee and manage borough based joint, primary and community service development, coordination and in year investment and business case approval in line with the scheme of delegation through membership of the group.

It is envisaged that in time delegated borough-based decision-making will be through Integrated Care Partnerships as these become formal entities, supported by the CCG borough based leadership teams. This formal delegation process through ICPs is yet to be fully developed and may in-time supersede the need for specific borough based groups or sub-committees as proposed above.

Development of the financial principles

In planning future spending, CCGs principles will still need to support and be in line with the following national and legal financial restrictions and guidance:

a) Implementation of the NHS Long Term Plan

As part of the national planning approach the NCL CCGs need to submit a five year finance and activity plan setting out finance and activity assumptions based on the delivery of the NHS Long Term Plan.

This includes the indicative allocations across providers. Detailed work on this is taking place through local director leads and Governing Bodies, and system plans should be agreed with regional teams, in consultation with National Programme Directors, by 15 November 2019.

This strategic planning will support and inform operational planning in 2020/21, and strategic plans will provide the basis for agreeing indicative contract values and activity levels for 2020/21 as well as setting out clear direction of travel for the next four years.

b) The Mental Health Investment Standard

The Mental Health Investment Standard (MHIS) was previously known as Parity of Esteem (PoE) and is the requirement for CCGs to increase investment in Mental Health (MH) services in line with their overall increase in allocation each year.

c) Primary Care contracts

The North Central London CCGs (‘NCL CCGs’) became responsible for fully delegated primary care commissioning in 2017.

The NCL CCGs have robust and effective arrangements in place for delegated primary care commissioning. This includes the NCL Primary Care Commissioning Committee in Common between the CCGs to exercise oversight and decision making, a central NCL wide team for GP core contracting from NHS England who are now CCG employees, a central director with responsibility for delegated primary care commissioning who is a member of the CCGs’ central Senior Management Team, reports directly to the Accountable Officer and works with the

112112

NCL CCGs


P a g e | 41

primary care teams in each of the CCGs. The CCGs’ internal auditors (RSM) recently conducted an audit on commissioning and procurement of services and found that there was ‘reasonable assurance’.

The above arrangements would smoothly transition to a new single CCG with a single Primary Care Commissioning Committee providing oversight of the arrangements and exercising decision making in accordance with NHS England statutory guidance.

d) Medium Term Financial Strategy

The NCL Health economy has an underlying deficit of £200m per year. Work is underway to develop a medium term financial plan, which will outline the work needed to support the financial sustainability of the health service, with a plan across multiple years to reduce and remove costs out of the system through a set of collective actions across NHS partners.

The financial principles will need to underpin the delivery of the MTFS, which is plan is still in development but has the following emerging themes:

Look at limiting acute trust income growth to less than 2% from 2020/21 - 2023/24

Focus on organisational recovery plans in light of the constrained income environment

Reduce demand and activity growth particularly non elective through out of hospital services and primary care

The Medium Term Financial Strategy will be developed collaboratively across all NCL NHS organisations and will be signed up to by all NHS organisations in North Central London to support future planning and delivery of services.

Growth in allocation:

The published allocations for the CCGs are as follows. The growth per year figure varies based on how far from target allocation each borough is (historic underfunding/overfunding).

These allocations are part of the deployment of NHS England’s five-year revenue funding settlement, averaging 3.4% a year in real terms and reaching £20.5bn extra a year by 2023/24. CCG allocations are being set on the basis of NHS England’s five-year real terms revenue funding profile, which has now been set by Government as 3.6%, 3.1%, 3.0%, 3.0% and 4.1%.

NCL CCGs Core services allocation

CCG Core Services 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24

Barnet Allocation £'000 495,248 525,288 549,103 572,344 594,819 616,339

Headline growth £'000 30,040 23,815 23,241 22,475 21,520

Headline growth % 6.07% 4.53% 4.23% 3.93% 3.62%

Camden Allocation £'000 364,048 381,741 394,402 405,504 415,801 425,897

Headline growth £'000 17,693 12,661 11,102 10,297 10,096

Headline growth % 4.86% 3.32% 2.81% 2.54% 2.43%

Enfield Allocation £'000 412,335 436,688 455,965 474,835 493,181 510,795

Headline growth £'000 24,353 19,277 18,870 18,346 17,614

Headline growth % 5.91% 4.41% 4.14% 3.86% 3.57%

Haringey Allocation £'000 364,654 387,514 406,674 424,952 442,408 458,759

113113

NCL CCGs


P a g e | 42

Headline growth £'000 22,860 19,160 18,278 17,456 16,351

Headline growth % 6.27% 4.94% 4.49% 4.11% 3.70%

Islington Allocation £'000 352,245 371,367 385,578 398,834 411,092 422,565

Headline growth £'000 19,122 14,211 13,256 12,258 11,473

Headline growth % 5.43% 3.83% 3.44% 3.07% 2.79%

NCL Allocation £'000 1,988,530 2,102,598 2,191,722 2,276,469 2,357,301 2,434,355

Headline growth £'000 114,068 89,124 84,747 80,832 77,054

Headline growth % 5.74% 4.24% 3.87% 3.55% 3.27%

NCL CCGs Primary Medical allocation

CCG Primary Medical 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24

Barnet Allocation 51,330 54,797 57,463 60,807 63,533 66,363

Headline growth 3,467 2,666 3,344 2,726 2,830

Headline growth % 6.75% 4.87% 5.82% 4.48% 4.45%

Camden Allocation 37,814 40,397 42,293 44,846 47,252 49,280

Headline growth 2,583 1,896 2,553 2,406 2,028

Headline growth % 6.83% 4.69% 6.04% 5.37% 4.29%

Enfield Allocation 43,225 46,040 48,083 50,684 52,775 54,931

Headline growth 2,815 2,043 2,601 2,091 2,156

Headline growth % 6.51% 4.44% 5.41% 4.13% 4.09%

Haringey Allocation 43,054 45,855 47,862 50,412 52,444 54,523

Headline growth 2,801 2,007 2,550 2,032 2,079

Headline growth % 6.51% 4.38% 5.33% 4.03% 3.96%

Islington Allocation 37,321 39,988 41,920 44,292 46,160 48,055

Headline growth 2,667 1,932 2,372 1,868 1,895

Headline growth % 7.15% 4.83% 5.66% 4.22% 4.11%

NCL Allocation 212,744 227,077 237,621 251,041 262,164 273,152

Headline growth 14,333 10,544 13,420 11,123 10,988

Headline growth % 6.74% 4.64% 5.65% 4.43% 4.19%

114114

NCL CCGs


P a g e | 43

Proposed financial principles

The starting point for a single CCG will be the borough based allocations of funding and services they have now. The budgets will be set for 20/21 on this borough basis ahead of the merger through the current CCG governance structures.

The future NCL CCG will not disinvest in non-acute services in any boroughs and will over time look to increase investment in these areas where it can reduce or support lower levels of growth in acute budgets and reduce health inequalities within and across boroughs. This will support the delivery of the medium term financial strategy.

This is the starting point for future system planning, detailed work on this is taking place through local director leads and governing bodies and system plans should be agreed with regional teams, in consultation with National Programme Directors by 15 November 2019.

This strategic planning, completed by the current NCL CCGs before April 2020 will support and inform operational planning in 2020/21 and strategic plans provide the basis for agreeing indicative contract values for 2020/21 and activity levels as well as setting out clear direction of travel for the next four years.

Borough teams will continue to commission enhanced primary care services under an agreed framework.

The NCL CCG will continue to meet the mental health investment standard in line with national guidance. This will be on an NCL wide basis in line with national guidance, to allowing for differential approaches by provider in line with the Medium Term Financial Strategy (MTFS) to ensure new investment supports lower levels of growth in acute hospitals and delivers value for money across the system. It should be noted that this principle is complementary to the principle of not disinvesting in mental health services across boroughs.

The above principles will continue to be worked on and developed over the time ahead of merger. With input from both the current CCGs and any shadow arrangements for the new CCG. It is proposed that a schedule is included in the new constitution for the NCL CCG which will provide assurance that these principles will be honoured.

CCG Accumulated Deficits and Surpluses

The following approach for treatment of historical deficits / surplus has been agreed with the Director of Operational Finance (SW, SE and NW London), and the Interim Regional Director of Finance (London), on behalf of NHS England / Improvement:

The priority for all CCGs (and hence for the merged NCL CCG) is to return to financial sustainability - i.e. recurrent run rate balance;

The minimum planning cumulative surplus requirement for CCGs is currently 1% of allocation. However, for CCGs moving back into financial sustainability from deficit positions there will be discussions with local system leaders to agree what is reasonable to deliver within plans and over what length of time;

Given the existing underlying deficit across the NCL CCGs for 2019/20, returning to recurrent run rate balance is likely to take some years and recovery to a 1% surplus therefore a bit longer. Accumulated deficits would only start to be addressed once the merged NCL CCG moves back into surplus;

NHS London will discuss and agree with NCL the planning assumptions to ensure the trajectory back to run-rate balance and then to modest surplus is deliverable, reasonable, fair and does not penalise investment in key LTP priority areas. This could include consideration of ‘freezing’ an element of the accumulated deficit, particularly where deficits were incurred at a time when CCGs were funded below target allocation;

115115

NCL CCGs


P a g e | 44

Additionally, the impact of mergers on deficit repayment profiles should be made ‘neutral’ – what that effectively means is that the merged CCG should not be required to deliver any additional improvement to the financial position of the merged CCG than could have been delivered if the CCGs did not merge;

The national finance team is currently reviewing the impact that the future repayment profiles may have on mergers, and are keen to make sure that an equitable approach is taken which is also supportive of the current programme of CCG merger. Further details in the policy proposal will be available in due course.

Ensuring Strong Financial Management

The new CCG will work to ensure it meets its key financial duties set out by the NHS England for CCGs as a statutory body through:

Clear and effective arrangements setting out the financial duties of the new governing body and statutory role holders within this;

Robust financial procedures and controls;

Effective financial management and financial planning arrangements; and

Comprehensive financial systems, operated by well-managed, adequately resourced and suitably trained staff.

As an example of this, the Finance Committee and Governing Body will receive regular reports on the financial performance of the CCG to provide assurance and documentary evidence of performance for contractual elements of performance. This will also include regular reviews of, but not limited to: Draft Financial Plan, Final Financial Plan, monthly QIPP reports, risk registers and ad-hoc reports and information as required. The CCG will also submit monthly and quarterly information as required to NHS England as part of the CCG assurance processes.

The Finance Committee will meet on a regular basis to review the financial position and identify mitigating actions to ensure we deliver our financial plan.

Alongside this, the NCL CCG will have an Audit Committee whose role will centre on ensuring the adequacy and effectiveness of the organisation’s overall internal control systems. The Audit Committee operates on behalf of the Governing Body and through the work of the Audit Committee, the Governing Body will be assured that effective internal control arrangements are in place.

The remits of these Committees are further detailed in Appendix C below.

116116

NCL CCGs


P a g e | 45

Appendix C: Further Governance Arrangements

Committee Remits

The key remits of the respective Committees of the Governing Body are as follows:

Strategy and Commissioning Committee (excluding primary care):

Development and oversight of commissioning strategy for the CCG;

Approval of strategic business cases- outcomes and financial envelope;

Approval of statutory commissioning plans;

Approval of annual operating plans;

Commissioning at a system level;

Oversight of contracting round;

Acute commissioning;

Strategic and specialist mental health commissioning;

Arrangements for commissioning of Specialist Services delegated to the CCG by NHS England;

Commissioning activity not overseen by the borough groups / sub-committees or future partnership boards;

Development of QIPP commissioning strategy.

Primary Care Commissioning Committee:

Development and oversight of primary care strategy for the CCG;

Exercises delegated authority from NHS England for primary care commissioning;

GP core contracting;

Approval of Locally Enhanced Services and Local Incentive Schemes that fall within the remit of the Committee;

Considers recommendations with regards to primary care from partnership boards.

Individual Funding Request Panel and Individual Funding Request Appeals Panel:

Makes decisions on individual funding requests applications;

Considers and follow the CCG’s IFR Policy when determining the outcome of individual funding requests applications;

Remits decisions for individual funding requests over the panel’s financial authority limits to the appropriate decision makers.

Finance Committee:

Oversight of finance and financial management arrangements for the CCG;

Oversight of strategic performance that impacts the finances of the CCG;

Approval of budgets and oversight and assurance of financial performance and budget monitoring;

Oversight of contract performance and contract negotiations

117117

NCL CCGs


P a g e | 46

Oversight of QIPP development and delivery;

Oversight and assurance of commissioner and provider performance against Constitutional and contractual targets.

Quality and Safety Committee:

Oversight and assurance of the quality and safety of commissioned services;

Oversight and assurance that patients have effective and safe care with positive experience of services;

Oversight and assurance of safeguarding and complaints;

Oversight of patient related provider performance (individual cases and aggregated performance)

Oversight of CDOP activity.

Patient & Public Engagement and Equalities Committee:

Oversight and assurance that effective engagement and involvement is taking place across NCL and throughout the CCG and that the CCG is meeting its statutory duties and the IAF criteria;

Oversight of the CCG’s engagement/involvement strategy, action plan and activity;

Ensures that meaningful engagement is undertaken to help inform commissioning and commissioning decisions and that the CCG is acting on the feedback from local communities;

Supports and helps to ensure co-ordination and consistency of local engagement activity undertaken through borough-based partnership working;

Sharing good practice and successes in local engagement work with other parts of NCL;

Advocates to ensure the CCG’s engagement and involvement approach follows best practice, is streamlined and enables the CCG to demonstrate the value and benefits to residents;

Oversight of the CCG’s equality, diversity and inclusion strategy, action plan and activity;

Ensuring the CCG is successfully holding providers to account for their engagement and equalities duties.

Audit Committee:

Reviews the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the CCG’s activities that supports the achievement of its objectives;

Ensures that there is an effective internal audit function that meets the Public Sector Internal Audit Standards 2013 and provides appropriate independent assurance to the audit committee, Accountable Officer and Governing Body;

Reviews and monitors the external auditors’ independence and objectivity and the effectiveness of the audit process;

Reviews the findings of other significant assurance functions, both internal and external to the CCG, and consider the implications for the governance of the CCG;

Satisfies itself that the CCG has adequate arrangements in place for counter fraud and security that meet NHS Counter Fraud Authority’s standards and reviews the outcomes of work in these areas;

Monitors the integrity of the financial statements of the CCG and any formal announcements relating to its financial performance;

118118

NCL CCGs


P a g e | 47

Reviews the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.

Remuneration Committee:

Approve Governing Body and Clinical Lead pay levels;

Approve organisational pay policy;

Make recommendations on pay levels for Very Senior Managers (in line with the NHS England guidance for the new Model Constitution).

Medicines Management sub-committee:

The proposed governance structure includes a Medicines Management sub-committee – reporting into the Quality and Safety Committee. The proposed remit of the Medicines Management sub-committee is:

Oversight and assurance of the CCG’s statutory functions on medicines;

Oversight and assurance on medicines and that safe, effective and value for money medicines are available and their proper use is promoted;

Ensures appropriate treatments are available and appropriate governance and systems are in place to support decisions on the funding of treatments and drugs;

Approval of medicines policies, prescribing guidelines, clinical pathways and any other information involving medicines for clinicians and patients within the CCG’s commissioning responsibilities;

Identification of QIPP opportunities and monitoring of prescribing spend to inform budgets.

The work of the Medicines Management sub-committee will need to be considered in the context of borough-based activity on Medicines Management.

Core Governance Principles

A significant amount of work has already been undertaken to ensure the NCL CCGs work to common governance arrangements. In the last year, this has included the CCGs all agreeing a single strategic approach to Risk Management and a range of single Governance Policies. Substantial work has also been undertaken to draft a single set of Standing Financial Instructions for NCL – and a common Constitution. Work is also currently being undertaken to harmonise all HR policies. All of this work very much supports the move to a single CCG for North Central London. Going forward, the CCG will have a comprehensive governance and risk management framework which includes: Operating under a robust set of governance principles representing best practice;

A Constitution based on the new NHS England Model CCG Constitution;

Supporting Constitutional documents - including Standing Orders, Scheme of Reservation and Delegation, Prime Financial Policies and Standing Financial Instructions;

A robust risk management framework, supporting policies and documents;

A full suite of governance policies such as:

o Conflicts of Interest;

o Gifts, Hospitality and Sponsorship;

119119

NCL CCGs


P a g e | 48

o Counter Fraud, Bribery and Corruption;

o Information Governance and Security;

A membership vote will be undertaken to approve the new Constitution for the NCL CCG. It is proposed that this work will be undertaken immediately after the Governing Bodies’ decision to submit the merger application to NHS England – with a view to the voting process being concluded by 25th October 2019.

Local decision-making and Integrated Care Partnerships

Without compromising the robustness of the governance arrangements in place, it is recognised that some flexibility will be required as the commissioning / provider landscape evolves across North Central London (in the context of meeting the requirements of the NHS Long Term Plan and the introduction of an Integrated Care System (ICS) and Integrated Care Partnerships (ICPs)).

Under the proposed operating model for the single CCG, with borough-based teams working on:

primary care commissioning;

joint community (including children’s and some elements of learning disability joint commissioning) and mental health commissioning;

local medicines management activity;

local safeguarding work;

local transformation programmes.

It will be important for local decision-making arrangements to be developed alongside the Governing Body Committee arrangements as set out above. This will need to be reflected in the Scheme of Delegation and Standing Financial Instructions. The proposed borough-based decision-making arrangements are set out in Appendix B of this document – and may take the form of borough-based groups or sub-committees of the NCL Strategy & Commissioning Committee. The associated governance arrangements will be developed ensuring robust levels of accountability and transparency.

It is envisaged that, in time, much of this delegated borough-based decision-making will be through Integrated Care Partnerships.

Clinical Leadership

In addition to elected representatives on the Governing Body, the provision of strong specialty clinical leadership, is a key part of the CCG’s commissioning role to improve health outcomes.

As part of preparing for the proposed single CCG for North Central London – a full schedule of all Clinical Lead roles has been produced – including those working with individual CCGs and those involved in progressing STP-level priorities across the NCL footprint. The latter has demonstrated, from both a consistency and efficiency perspective, the benefit of Clinical Lead roles across the wider footprint.

As part of our governance work to prepare for a single CCG we are undertaking an immediate priority to review and agree:

A strategic approach for identifying the portfolio areas that require specialist Clinical Lead capacity;

The optimum balance between NCL-wide clinical lead roles and roles required to support borough-based integrated care partnerships;

Clear and consistent paths of accountability for, and oversight of, clinical lead activity;

A model that, where required, allows flexibility in clinical lead arrangements as new priorities develop;

120120

NCL CCGs


P a g e | 49

Consistency of approach for clinical leads’ terms and conditions.

In anticipation of a potential merged CCG from April 2020 – current terms for existing CCG Clinical Leads are being extended up to 31 March 2020, thereby allowing the outputs from the above review work to be introduced in a timely and value-added manner.

121121

NCL CCGs


P a g e | 50

Appendix D: Governance Transition Plan

The merger of the North Central London CCGs in April 2020 will mean adopting new governance structures across NCL with an aim of reducing unnecessary and duplicative decision-making. The key governance milestones through transition will include:

No. Steps Dates

1 Attend NHS England Formal Assessment Panel 9 October 2019

2 Complete membership vote on new Constitution 25 October 2019

3 Complete review of Clinical Leadership 30 November 2019

4 Secure NHS England support to merge NCL CCGs 30 November 2019

5 Plan and launch elections for elected Governing Body roles with new GB members being selected by early February 2020:

a) Planning and preparation

b) Election launched

c) Ballot

d) Ratification of process and results at Governing Body meetings

November 2019 – March 2020

4 November 2019

2 December 2019

20 January - 9 February 2020

March 2020

6 Recruitment of appointed Governing Body members 2 December 2019 – 7 February 2020

7 Commence process to elect / appoint GB Chair, Deputy (lay) Chair, Clinical Vice Chair

10 February

8 Deliver new Governing Body member induction sessions 17 February – 31 March 2020

9 Governing Body shadow arrangements in place and operating (for decisions solely relating to the future CCG)

24 February 2020 – 31 March 2020

10 Alignment check of all corporate governance policies 2 December 2019 – 31 January 2020

11 Development of Terms of Reference for Governing Body committee structure

4 November 2019 – 18 December 2020

12 First Governing Body meeting with approval of governance documentation

Post 1 April 2020

122122

NCL CCGs


P a g e | 51

Appendix E: Letters of Support

123123

124124

Interim Chair: David Holt Chief Executive: Siobhan Harrington

10 September 2019

Helen Pettersen Accountable Officer and STP Convener Haringey CCG River Park House 225 High Road Wood Green N22 8HQ Dear Helen Following recent liaison with you and other senior NCL CCGs staff, I am writing to confirm my organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients.

In order for us to focus on key priorities and deliver models of integrated care that will support the changes needed in NCL, reducing bureaucracy and transactional meetings and tasks will be most important. We need as a system to reduce duplication and to challenge ourselves to work smarter.

I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely, Siobhan Harrington Chief Executive

Executive Offices Magdala Avenue

London N19 5NF

Tel: 020 7288 3636

020 7272 3070 [email protected]

Web: www.whittington.nhs.uk

Helping local people live longer healthier lives 125125

126126

Trust Headquarters, 350 Euston Road, London NW1 3AX

Telephone: 020 3214 5700 www.cnwl.nhs.uk

Executive Office Tel: 020 3214 5760

5 September 2019 Helen Pettersen Accountable Officer – Barnet, Camden, Enfield, Haringey and Islington Clinical Commissioning Groups and STP Convenor for North Central London 14th Floor, Euston Tower 286 Euston Road NW1 3DP Dear Helen, Further to our telephone conversation, I am writing to confirm Central and North West London NHS Foundation Trust’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients. I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely,

Claire Murdoch Chief Executive

127127

http://www.cnwl.nhs.uk/

Providing community healthcare Chair: Angela Greatley in London and the Home Counties Chief Executive: Andrew Ridley

Helen Pettersen NCL CCGs Accountable Officer River Park House 225 High Road, Wood Green N22 8HQ 2nd September 2019 Dear Helen Further to our telephone conversation, I am writing to confirm my organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients.

I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely

Andrew Ridley Chief Executive Office Central London Community Healthcare NHS Trust

Office of the Chief Executive Ground Floor

15 Marylebone Road London NW1 5JD

Tel: 020 7798 1300 Web: www.clch.nhs.uk

128128

http://www.clch.nhs.uk/

129129

130130

131131

Chair: Dr Peter Carter OBE Chief Executive: Maria Kane

Sterling Way London N18 1QX Direct Line 020 8887 XXXX Email: [email protected]

3 September 2019

Dear Helen I thought it would be helpful to confirm my organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. This is in accord with the conclusions of the ‘Inter-great’ simulation events, whereby merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and an NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for the residents and patients of Enfield, Haringey and beyond.

We hope that this will now address some historic funding anomalies, reduce commissioning fragmentation and enhance potential economies of scale.

I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely,

Maria Kane Chief Executive

132132


www.royalfree.nhs.uk

Dominic Dodd, chair

Caroline Clarke, group chief executive

4 September 2019 Helen Pettersen Accountable Officer NCL CCGs River Park House 225 High Road, Wood Green London N22 8HQ Dear Helen Further to our conversation, we are writing to confirm our organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. The potential gains of this approach, such as better health outcomes, improved patient experience, coupled with reducing demand on health and social care services are essential goals for our area. The way we manage and deliver health and social care services do not meet the current, and will not meet the future, health and care needs of our population in a sustainable way. We must change our approach to achieve these. The Royal Free Group is committed to this work and we will support this as best we can. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients. We are happy for this letter to be included within your merger application submission to NHS England. Yours sincerely

Caroline Clarke Kate Slemeck Steve Shaw Group chief executive Chief executive Chief executive Royal Free London Group of Hospitals Royal Free hospital Barnet hospital

133133

http://www.royalfree.nhs.uk/

134134

Helen Pettersen 9 September 2019 Chief accountable officer NCL CCG

Dear Helen Further to our telephone conversation, I am writing to confirm my organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients.

I am happy for this letter to be included within your merger application submission to NHS England.

Yours faithfully

David Probert Chief executive

135135

September 10, 2019

Dear Helen,

Following recent liaison with you and other senior NCL CCGs staff, we are writing to confirm our organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020.

In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System.

We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients.

Islington GP Federation (IGPF) is wholly-owned by Islington GPs. Our vision is to enable all Islington registered patients to have free and equitable access to good, safe, value for money primary care well into the future. This letter is aligned with this vision and, as such, represents the views of IGPF’s board of directors on behalf of its shareholders.

IGPF recognises and respects the role of the LMC in representing its members in Islington, whose GP practices are almost all IGPF shareholders. We are committed to collaborating with the LMC, driven by a shared vision to support general practice sustainability and strength of voice in this changing health and wellbeing landscape. We also acknowledge that the two organisations may on occasion have differing priorities and agendas, on the basis that they have different jobs to do. We remain committed to always seek a shared purpose and close allegiance.

In May 2019, Jonty Heaversedge presented at a North London Partners event. In it he described London’s model Integrated Care System: a key component of that system, he said, was a ‘Large-scale General Practice Organisation’, operating at borough level and he cited GP federations as that type of organisation. This contrasts with March 2019’s second Inter-great event summary, which contained no meaningful reference to such ‘at scale’ GP organisations that had featured heavily in the outputs of late 2018’s first Inter-great event.

IGPF’s support in this letter assumes that you see IGPF as a LGPO and, as such, as key to the development of NCL’s ICS as in the model described by Jonty on behalf of NHS, HLP and NCL in May. On that basis we will commit energy, time and

136136

resources into our continued participation in Islington’s borough partnership design process. We will also expect to play an active and material role within the governance structure under development for NCL’s ICS, in support of and in addition to Islington PCN representation by PCN clinical directors. We believe that it is imperative that the emerging system recognises the critical role that LGPO’s will play in the development of PCNs over the next 5 to 10 years. This recognition needs to be built into NCL’s strategic communication and operational governance in order to be clear to all organisations participating in this exciting system change opportunity.

Additionally, IGPF has been working collaboratively with the other 5 federations in NCL and is committed to doing so as the system develops towards an ICS.

We are happy for this letter to be included within your merger application submission to NHS England.

Yours sincerely,

Dr Benedict Smith, Chair, The Islington GP Group Ltd (Islington GP Federation)

Mike Clowes, CEO, The Islington GP Group Ltd (Islington GP Federation)

137137

138138

Chair: Natalie Ker Watson Medical Director: Dr Will Zermansky Chief Executive Officer: Cassie Williams

Hornsey Central Neighbourhood Centre

151 Park Road London N8 8JD

www.federated4health.com

[email protected]

5th September 2019

Dear Helen Following recent liaison with you and other senior NCL CCGs staff, I am writing to confirm Federated4Health’s (Haringey’s GP Federation) support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients. I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely

Cassie Williams Chief Executive Officer Federated4Health

139139

http://www.federated4health.com/


140140

Nesil Caliskan Leader of the Council Phone: 020 8379 4116 Enfield Council Email: [email protected] Civic Centre, Silver Street Website: www.enfield.gov.uk Enfield EN1 3XA

If you need this document in another language or format contact us using the details above. ?

Helen Pettersen Accountable Officer for North Central London CCGs

9 September 2019

Dear Helen, I am writing to confirm my organisation’s support for the North Central London clinical commissioning groups’ proposal to merge from 1 April 2020. In line with the conclusions of the “Inter-great” simulation events, this merger will support the development of a streamlined NCL health commissioning function and a single set of system-level commissioning decisions, while assisting the development of strong borough partnerships and NCL Integrated Care System. We look forward to working with you to build on the collaborative approach developed in NCL over the last two years, through our STP and most recently between partners on planning for an integrated system to deliver benefits for our residents and patients. The key priorities for our residents include strengthening Primary Care and Mental Health services, ensuring the viability and quality of North Middlesex Hospital and Chase Farm Hospital, responding to youth violence and reducing stalk health inequalities in the Borough. As you are aware as a Council, we are very keen to use our significant influence and resource to ensure through a ‘placed based’ approach these issues are address in partnership with the NHS. I am happy for this letter to be included within your merger application submission to NHS England. Yours sincerely,

Cllr Nesil Caliskan Leader of Enfield Council

141141

142142


Report Title Approval of Decisions Taken by the NCL Joint Commissioning Committee

Agenda Item 4.1

Governing Body Sponsor

Not applicable Email


Ian Porter, NCL Director of Corporate Services Paul Sinden, Director of Performance, Planning and Primary Care for NCL CCGs

Email [email protected] [email protected]

Report Author

Andy Simpson, Board Secretary, Barnet CCG

Email [email protected]

Report Summary

1. The North Central London Joint Commissioning Unit (NCL JCC) is a joint committee established to make decisions on behalf of NCL CCGs in relation to range of commissioning areas, including integrated urgent care; acute services; and specialist commissioning (with delegated responsibility by NHS England).

2. Unlike other NCL CCGs, Barnet CCG’s Constitution does not delegate

authority to the NCL Joint Commissioning Committee (JCC) to make decisions on its behalf, meaning that the CCG’s Governing Body is required to approve all decisions taken at meetings of the JCC.

3. The agreed process in place currently is that all minutes approved by

the JCC are considered by the CCG’s Governing Body at its next meeting in public in order to gain approval of decisions made by the JCC. This means that decisions made at a JCC could potentially need to wait for three months until they are approved.

4. The JCC took the following decisions at its meeting held on 6 June

2019, for which this paper seeks Governing Body approval:

APPROVED the month twelve (M12) Acute Contracting Report; APPROVED the 2018-19 Acute Services Quality and Performance

Report; APPROVED a recommendation to write to NHS England to request

clarification on 2019-20 funding arrangements; AGREED with the adoption of the term ‘Evidence Based

Interventions and Clinical Standards’ to replace ‘Procedures of Limited Effectiveness’ and with restructure the supporting document to clarify why different procedures had been included in the policy

5. In order to increase the level of efficiency with which decisions are

made by the JCC, and minimise the risk of delays to urgent decisions being enacted as a result of the current process, it is proposed that the

143143




Barnet CCG Governing Body delegates ongoing authority to the following individuals to approve decisions made by the JCC:

Dr Charlotte Benjamin – Chair of the Governing Body and Member

of JCC Dominic Tkaczyk – Lay Member of the Governing Body (Audit and

Governance) and Member of JCC Helen Pettersen – Accountable Officer of NCL CCGs and Member

of JCC

6. Ongoing delegation of authority would mean that the Governing Body has delegated decision making powers to the individuals named above to approve the decision taken by the JCC immediately after each of its meetings, rather than the current approach of waiting until the next meeting of the Governing Body.

7. Meeting papers for the JCC meetings can be viewed here.

The Governing Body is asked to:

APPROVE the decisions taken by the JCC at its meeting on 6 June 2019 (detailed at paragraph 4); and

APPROVE the delegation of ongoing authority to the individuals listed at paragraph 5 to approve decisions made by the JCC.


Any decision not to approve decisions taken by JCC may have an implication on the associated commissioning activity.


No conflicts arise as a result of the Governing Body’s approval of JCC decisions or ratification of the Chair’s Action


Not Applicable

Engagement

Not Applicable


Not Applicable


Not Applicable – this is a standard report to seek the Governing Body’s approval of decisions made by the JCC

Appendices

Minutes of JCC meeting held on 6 June 2019

144144

http://www.enfieldccg.nhs.uk/about-us/ncl-joint-commissioning-committee.htm

1

NORTH CENTRAL LONDON (‘NCL’) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday, 6 June 2019, 2.30pm – 5pm

Council Chamber, Crowndale Centre, 218 Eversholt St, London NW1 1BD Voting Members Present: Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG Dr Mo Abedi Governing Body Chair, Enfield CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG Dr Peter Christian Governing Body Chair, Haringey CCG Ms Kathy Elliott (Vice Chair) Governing Body Lay Member, Camden CCG Dr Neel Gupta Governing Body, Chair, Camden CCG Ms Catherine Herman Governing Body Lay Member, Haringey CCG Dr Fawad Hussain Governing Body Secondary Care Clinician, Enfield CCG Ms Helen Pettersen Accountable Officer, Barnet, Camden, Enfield,

Haringey and Islington CCGs Dr Jo Sauvage Governing Body Chair, Islington CCG Mr Dominic Tkaczyk Governing Body Lay Member, Barnet CCG Non-Voting Members Present: Ms Sharon Grant Healthwatch Haringey Ms Parin Bahl Healthwatch Enfield Attendees: Ms Pat Callaghan Councillor, Camden Council Ms Eileen Fiori NCL Director of Acute Commissioning Ms Jenny Goodridge Director of Quality and Clinical Services, Barnet CCG Ms Kath McClinton Senior Responsible Officer, Transforming Care Programme Mr Ian Porter Director of Corporate Services, Barnet, Camden, Enfield,

Haringey and Islington CCGs Ms Sarah Rothenberg NCL POD Director, NELCSU Mr Paul Sinden NCL Director of Planning, Performance and Primary Care Apologies: Dr Charlotte Benjamin Governing Body Chair, Barnet CCG Ms Janet Burgess Councillor, Islington Council Ms Alev Cazimoglu Councillor, Enfield Council Ms Tamara Djuretic Director of Public Health, Barnet Council Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield,

Haringey and Islington CCGs Ms Sarah James Councillor, Haringey Council Mr Ed Nkrumah NCL Director of Performance Mr Adam Sharples Governing Body Lay Member, Haringey CCG Mr Daniel Thomas Councillor, Barnet Council Minutes Mr Steve Beeho Board Secretary, Haringey CCG 1 Introduction 1.1 Apologies for absence 1.1.1

Apologies were received from Charlotte Benjamin, Janet Burgess, Alev Cazimoglu, Tamara Djuretic, Simon Goodwin, Sarah James, Ed Nkrumah, Sharon Seber, Adam Sharples and Daniel Thomas.

145145

2

1.2 Declarations of Interests 1.2.1

There were no additional declarations of interests.

1.3 Declarations of gifts and hospitality 1.3.1

There were no gifts or hospitality offered or received.

1.4 Opening Remarks 1.4.1

The Chair welcomed everybody to the meeting.

1.5 Questions from the public 1.5.1 1.5.2

The Committee noted the responses to the written questions submitted in advance of the Committee. Terms of reference for the Committee would be updated to allow flexibility for the timing of accepting deputations in the event of meeting papers being published the week before a Bank Holiday or being published late. ACTION: Ian Porter to arrange for the wording relating to deputations to be amended in the next review of the Standing Orders to allow for greater flexibility in the event of Bank Holidays.

2. Governance 2.1 Minutes of Committee Meetings on 4 April and 2 May 2019 2.1.1 2.1.2

The Committee APPROVED the minutes of the meeting on 4 April 2019 as an accurate record, subject to the reference to JCC meetings in section 7.3.2 being amended to Directors of Quality Meetings. The Committee APPROVED the minutes of the meeting on 2 May 2019 as an accurate record, subject to Dominic Tkaczyk’s name being added to the list of individuals who had given their apologies.

2.2 Action Log 2.2.1 2.2.2 2.2.3 2.2.4

The Committee reviewed the action log. The majority of the actions had been discharged. It was agreed that action 69 could be closed, as this would be picked up under item 4.3 on the meeting agenda. Paul Sinden provided a verbal update for action 73, noting that the Enfield CCG 2019-20 acute contracts include new investment in the rapid response pathway, the community ophthalmology service and the clinical service for cardiac triage. It was agreed that this action could also now be closed. The Committee NOTED the action log.

2.3 Minutes of Committees in Common meeting 2.3.1

The Committee NOTED the minutes of the Committees in Common meeting held on 24 April 2019 for Project Oriel.

146146

3

2.3.2 2.3.3

It was confirmed that Healthwatch representatives would be invited to future Committee in Common for Project Oriel. ACTION: Will Huxter to confirm Healthwatch invites to future Committees in Common.

3. Contracts and Planning 3.1 Finance and Activity Report 3.1.1

Sarah Rothenberg provided an overview of the report: For 2018/19 over-performance on all acute contracts was £72m (5.9%),

predominantly relating to the four main acute contracts in NCL. The deterioration from Month 11 (£10m), was primarily caused by £8m of provision changes and year-end adjustments by CCGs rather than from activity changes;

The reported position included year-end settlements with Royal Free London (RFL), NMUH and Barts. The RFL settlement included all prior year legacy issues;

Acute QIPP delivery across the 4 main acute contracts was £29m (45% of plan), with delivery particularly challenging for Enfield CCG where financial recovery plans were longer standing, and quick QIPP wins had been gained from prior year programmes;

Accepted claims and challenges up to Month 11 totalled £20.3m, with the highest value accruing from the major non-elective counting and coding challenge at Royal Free London;

All in-sector acute contracts for 2019/20 had been agreed following settlement of the UCLH contract, and signed except for the Royal Free and UCLH, which had been agreed but not signed. The signing of both contracts was planned to take place by the end of June 2019;

Acute contract forms varied for 2019/20 with ULCH on a block contract (and for 2020/21), Whittington Health on a Payment by Results contract, and Royal Free London and NMUH on a ‘Cap and Collar’ contract setting out maximum and minimum amounts that would be paid in-year. In addition the NMUH contract allowed for a marginal rate recovery from QIPP schemes below the collar amount if activity fell sufficiently;

The nature of the agreed acute contracts (especially the block ones) would impact on financial QIPP delivery in 2019-20, but full effects would be built into contract baselines for 2020/21. To support this QIPP delivery reports would now focus on both activity and cost reductions, and report by Trust as well as by workstream;

A more collaborative approach for claims and challenges had been agreed with providers for 2019/20. Technical/automated challenges would remain unchanged but manual challenges were expected to decrease due to changes in behaviour that both providers and commissioners had agreed to. This would be supported by the agreement of all prior-year issues with Royal Free London providing the contact with a clean-slate for 2019/20;

The materiality of any challenges would be jointly assessed and monitored with providers, and rapid close-down supported by early escalation to the Director of Acute Commissioning where required;

Reported activity trends were for March 2019. Month 1 data for 2019/20 was not yet usable due to quality issues, but a report on activity trends would be provided for the Committee Seminar in July 2019;

Activity trends for elective pathways showed a year-on-year reduction for GP referrals, but an increase in outpatient first attendances. This was being addressed by the planned care workstream including the continued expansion of Clinical Advice

147147

4

3.1.2

and Guidance. Outpatient follow-ups were stable year-on-year with work underway with providers to reduce the number of follow-ups in 2019/20 as part of the NHS Long Term Plan ambition to reduce outpatient face-to-face attendances by 30% over the next five years;

Electives saw year-on-year increases of 4%, largely driven by the specialities with higher outpatient attendances, including ophthalmology, dermatology and gastroenterology. Part of the increased activity at Whittington Health was attributable to the reintroduction of capacity which had been lower in previous years as a result of staff vacancies;

For non-elective pathways growth accrued from A&E attendances (3.1%) and zero length of stay (0LOS) emergency admissions (particularly ay NMUH and Royal Free London), with the latter not accompanied by a corresponding drop in admissions of 1 day or more;

The increase in zero length of stay (0LOS) emergency admissions at NMUH and the Royal Free London had resulted in joint clinical audits with the Trusts being undertaken. A summary of the audit outcomes would be shared with the Committee following sign-off by both parties;

Activity trends, including the impact of QIPP delivery, would be monitored in 2019/20 through Local Delivery Groups and contract meetings. In addition, Outpatient Transformation Boards were being introduced to optimise the targeted reduction in outpatient attendances supported by benchmark data and dashboards that would be shared with the Committee;

The Committee then discussed the report: Confirming that acute QIPP delivery in 2018/19 was 3% in line with QIPP targeted for

2019/20. Slippage in 2018/19 was in the context of a high 6% planning assumption; It was hoped that the alignment of the regulatory framework following the coming

together of NHS England and NHS Improvement would support a more collaborative approach with providers, as indicated by recent joint system-wide meetings rather than the separate CCG and provider meetings held in previous years;

Assurance was given that all contractual/legacy issues with Royal Free London had been closed at the year-end, unlike in previous years;

Development of Integrated Care Systems would support system-wide working and providers and commissioners moving to a collaborative “single version of the truth” approach;

To support working collaboratively with Trusts it was important to agree a single process for checking counting and coding against a defined set of principles with providers;

Confirmation was sought on whether there was a process in place for monitoring PoLCE (Procedures of Limited Clinical Effectiveness) in light of the recent changes. (This point would be picked up again under Item 4.3);

Assurance was given that the 2019-20 QIPP plans had been developed collaboratively by CCGs and STP workstreams. Establishing the NCL QIPP Directors meeting, chaired by Simon Goodwin, would support delivery and coherent planning assumptions;

Depending on the outcome the joint clinical audits with provides on zero length of stay (0LOS) emergency admissions could be a template for future ways of working with providers;

Confirmation would be provided outside the meeting on the purpose and dates of the forthcoming Engagement Advisory Board and Residents Panel meetings;

It was confirmed that updates on the work of the Outpatients Advisory Board would include details of patient and public engagement and how this will inform the next steps.

148148

5

3.1.3 3.1.4

The Committee: APPROVED the Acute Commissioning Report and ENDORSED the new approach to QIPP reporting. ACTION: Will Huxter to circulate the purposes and dates of the forthcoming

Engagement Advisory Board and Residents Panel meetings.

3.2 Acute Performance and Quality Report 3.2.1 3.2.2

Paul Sinden introduced the report, highlighting the following key points: Following the reporting of six Never Events by UCLH in March 2019, the Trust had

been invited to attend the seminar in July 2019. Camden CCG were working with the Trust and regulators to ensure on the investigation and lessons learned;

The recent Care Quality Commission (CQC) inspection of the Royal Free London FT resulted in an overall rating of ‘requires improvement’ compared to a “good” rating from the previous inspection. The Trust had already submitted an action plan to the CQC for the immediate actions requested, and the full plan would be submitted by 9 June 2019. Areas of concern from the inspection included theatre utilisation, timely discharge from critical care at Barnet Hospital and cultural issues at the Royal Free relating to theatre and medical teams. Barnet CCG had been working closely with the Trust in many of these areas;

There was concern nationally on the dip in A&E performance in 2019/20 to date compared to the corresponding period in 2018/19, with most concern locally focused on UCLH. CCGs were working with the Trust to improve performance through the Camden A&E Delivery Board. The national drive to improve performance focused on reducing extended lengths of stay in hospital beds, reducing ambulance handover times at emergency departments, and redirection of patients into primary care access hubs where appropriate;

Work on harmonising London Ambulance Service (LAS) capacity and performance across Boroughs included alternatives to conveyance to emergency departments, working with care homes to reduce calls, and the introduction of an additional vehicle to work across Barnet, Enfield and Haringey;

Call handling response times by the NHS 111 and GP Out-of-Hours service met the contract standard in April 2019, improving from the previous month;

The Referral to Treatment (RTT) data presented in the report excluded Royal Free London, following the Trust’s decision to cease national reporting from February 2019 due to a number of data quality issues identified during a review of reporting systems and processes. Local reporting had been developed by the Trust in lieu of this, and a steering group has been established, including NCL CCGs, NHS England and NHS Improvement, to ensure visibility of overall performance and the introduction of the new validation tool;

Since the publication of the report, Whittington Health, the Royal Free and NMUH had all achieved the 85% 62-day cancer waiting time operational standard in April 2019, bringing NCL’s aggregate performance up to 80%. UCLH performance in April 2019 was 70%.

In response to the report the Committee: Noted that the poor performance at NMUH against the 2-week breast cancer

symptomatic target was caused by a mammography capacity problem now resolved, but requested further assurance on access to the service;

Welcomed the positive impact on performance from investment in 2018/19 into the NHS 111 and Out of Hours service;

149149

6

3.2.3 3.2.4

Received assurance on the action being taken to address the previously-reported cultural issues in the Operating Theatres at Royal Free Hampstead, and that progress on this was monitored as a standing item by the Clinical Quality Review Group. It was agreed that progress updates would be included in a future Acute Performance and Quality Report;

Requested further information on the work to improve Friends and Family Test (FFT) scores at NMUH give the concern at performance being below NCL averages;

Noted concern at the lack of significant progress made in LAS performance, especially in outer London, give the recovery actions undertaken.

The Committee APPROVED the Acute Performance and Quality Report. ACTION: Paul Sinden to include the following in the next Acute Performance and Quality Report: Assurance on NMUH recovery of position for 2-week wait breast appointments; Update on the Royal Free London progress against the milestones to improve

their working culture, with site-specific data; Update on NMUH work to improve patient experience ratings in A&E; Update on actions taken by London Ambulance Service to improve response

times.

3.3 Transforming Care Programme Update 3.3.1 3.3.2

Kath McClinton provided a summary of the report, highlighting the following points: At 31 March 2019, the NCL Transforming Care Programme (TCP) had 55 inpatients,

against a target of 48. This represented a 33% reduction in the use of inpatient beds for this cohort across NCL from the April 2019 baseline, and compared favourably to a London-wide reduction of 19%;

NHS England had confirmed the programme would be extended until March 2021, with a further reduction in the use of inpatient beds agreed with NHS England;

NHS England had yet to confirm funding to CCGs to support the continuation of the programme into 2019/20. However, there is also likely to be an expectation of match-funding from CCGs and local authorities;

Further to the recent Panorama programme highlighting concerns about a facility in Durham run by Cygnet Healthcare, it was confirmed that there were no NCL patients at this facility. However, as Cygnet was a large provider of services for people with learning disabilities and had hospitals in the south east region, NCL currently had five patients in Cygnet-run facilities, four of whom were Haringey residents. Treatment reviews of these placements had been undertaken with no concerns identified;

Patients had treatment reviews every six months, and in the event of quality concerns being identified, local teams carried out unannounced visits;

Patients were increasingly being moved closer to London allowing the further development of treatment reviews and good working relationships with providers.

In response to the report the Committee: Welcomed the clarity of the report and the ‘lessons learned’ to date; Commended the treatment review process, supported by unannounced visits, to

provide assurance on the quality of care received by NCL patients; Noted the need to understand the recent ‘spike’ in admissions of children across

London. Linked to this there had been a number of instances of children being diagnosed late with autism which had increased admissions locally and Children’s Services were investigating this;

150150

7

3.3.3 3.3.4

In the absence of clarity on funding from NHS England for 2019/20 it was agreed that a letter from NCL CCGs, and ideally also from the five local authorities, should be sent to NHS England requesting final clarification on the 2019/20 funding arrangements. It was suggested that the pressures caused by the increasing prevalence of autism and the transition to adulthood should also be referenced in this letter.

The Committee: NOTED the report and AGREED the recommendation to write to NHSE to request final clarification on the

2019/20 funding arrangements. ACTION: Kath McClinton to co-ordinate a letter to NHS England on funding for 2019/20 Transforming Care Programme, ideally with local authorities.

4. Commissioning 4.1 NCL Adult Elective Orthopaedic Services Update 4.1.1 4.1.2

Will Huxter presented the drafting changes to the financial assessment of the options appraisal process verbally reported to the committee at the 2 May 2019 meeting. The Committee NOTED the drafting changes to the Clinical Delivery Model and Options Appraisal Process which had been approved by the Committee Chair under the authority agreed to be delegated at the 2 May 2019 meeting.

4.2 NCL Cancer Commissioning Update 4.2.1 4.2.2

Paul Sinden presented the overview of three key initiatives underway in NCL to improve services for patients diagnosed with, or suspected of being at risk of, cancer, and address priorities in the NHS Long Term Plan to deliver 75% of cancer diagnoses at an early stage and implement the 28-day Faster Diagnosis Standard from April 2020. The service developments included: The roll-out of the Faecal Immunochemical Test (FIT) for low-risk patients across

primary care in NCL from April 2019. Provisional data indicated an uptake in the use of the test in primary care, with less than 15% of patients requiring onward referral

The cancer Alliance had launched the largest lung cancer screening project in the UK, across north central and north east London, to improve early detection. The 15-month pilot was expected to yield earlier detection of over 200 lung cancer cases in NCL. Approximately 50% of practices across NCL had signed up to the study to date;

The Faster Diagnosis Standard would be introduced in April 2020. Under this, most patients would receive a definitive diagnosis or ruling out of cancer within 28 days of referral. Shadow running was currently taking place in preparation.

The Committee then discussed the report, making the following comments: Clarification was requested on when the FIT pathway would be mobilised for patients

with a higher-risk of cancer diagnosis; It was agreed that an equalities assessment would be undertaken on access to the

lung cancer screening project; A communications campaign should be developed to encourage practice and patient

take-up of the lung cancer screening programme; It would be helpful to involve patients in the design of communication materials for the

introduction of the Faster Diagnosis Standard;

151151

8

4.2.3 4.2.4 4.2.5 4.2.6 4.2.7

An update on readiness for the implementation of the Faster Diagnosis Standard by April 2020 would be brought to the Committee later in the year.

The Committee NOTED the service developments for cancer pathways in support of delivering priorities for cancer services the NHS Long Term Plan. ACTION: Ed Nkrumah to clarify when the second higher risk cancer pathway will be mobilised for qFIT. ACTION: Ed Nkrumah to arrange for an equalities assessment to be undertaken for the uptake of the lung cancer screening project. ACTION: Ed Nkrumah to consider the development of communications to encourage take-up of the lung cancer screening programme. ACTION: Ed Nkrumah to provide an update later in 2019/20 on NCL readiness to implement and measure the 28-day Faster Diagnosis Standard by April 2020.

4.3 Procedures of Limited Clinical Effectiveness (POLCE) update 4.3.1 4.3.2 4.3.3 4.3.4 4.3.5 4.3.6

Will Huxter introduced the report, recommending the PoLCE policy be renamed as ‘Evidence Based Interventions and Clinical Standards’ following feedback from stakeholders on the imprecise nature of the current term ‘procedures of limited clinical effectiveness (generally abbreviated to ‘PoLCE’). The recommended name change followed an engagement process with stakeholders. In the interests of accessibility, this name would be used in full, rather than reduced to an acronym. Communications for the policy had also been made more patient-focused by replacing the Frequently Asked Questions on the website with the answers to specific questions which have been asked. Subject to the committee’s approval of the proposed name change it was hoped that draft leaflets could be shared with Healthwatch at a meeting the following day and then with other community groups, to allow publication by the end of June 2019. The Committee then discussed the recommended name change and report: Work to make the policy more patient focused and understandable to the general

public needed to continue alongside the proposed name change; The name change would support the need to align with the relevant national

programme “Evidence Based Interventions” and London programme called Choosing Wisely. The second element of the proposed name (“Clinical Standards”) reflected the drive to achieve standardised approach to what were often complex decisions;

Application of the policy would need to be monitored to ensure it was applied equitably across population groups. This would be emphasised in the patient leaflet.

The Committee: AGREED to adopt the new name of ‘Evidence Based Interventions and Clinical

Standards’ and restructure the supporting document to clarify why different procedures had been included in the policy.

ACTION: Will Huxter to ensure that patient leaflets for Evidence Based Interventions and Clinical Standards explain clearly the appeals/complaints process.

152152

9

4.3.7 4.3.8

ACTION: Will Huxter to clarify how Healthwatch/patients can input into any Evidence Based Interventions and Clinical Standards-related communications. ACTION: Will Huxter to clarify how the Evidence Based Interventions and Clinical Standards process will be monitored.

5. Risk 5.1 NCL Joint Commissioning Committee Risk Register 5.1.1 5.1.2 5.1.3

Paul Sinden introduced the JCC Risk Register, highlighting the following: More detail relating to QIPP delivery would be added to Risk JCC26 in the next

review, as agreed in the teleconference; It will also be made clearer in the next update that the development of the Medium

Term Financial Strategy will mitigate Risk JCC28. In response to queries from the Committee, the following clarifications were provided: The learning from the after action reviews for winter 2018/19 were in the process of

being carried out by each A&E Delivery Board. These meetings would be followed by a pan-NCL meeting to discuss mutual aid across NCL. Once completed an update would be included in the next Acute Performance and Quality Report

An update report on the Medium Term Financial Strategy (Risk JCC28) would be brought to the Committee Seminar in September 2019.

The Committee NOTED the report and updates to the Committee risk register.

6. Items for Information 6.1 Glossary of Acronyms 6.1.1

The Committee NOTED the Glossary of Acronyms.

7. Any Other Business 7.1 Forward Planner 2018/19 7.1.1

The Committee NOTED the Forward Planner.

7.2 Deadline for Submission of Reports 7.2.1

The Committee NOTED that reports for the JCC meeting on 1 August 2019 should be sent to Paul Sinden by 22 July 2019.

8. Date of Next Meeting 8.1

The next Committee meeting would be on 1 August 2019.

153153

154154

Camden Clinical Commissioning Group

Governing Body Meeting

19 September 2019

Report Title NCL Primary Care Commissioning Committee in Common Terms of Reference

Agenda Item

4.2


Paul Sinden, Director of Planning, Performance and Primary Care


GB Member Sponsor

Report Author

Andrew Spicer, Head of Governance and Risk- NCL CCGs



N/A Summary of Financial Implications None.

Report Summary

At the Governing Body meetings in June 2019 it was agreed that the Terms of Reference for the NCL Primary Care Commissioning Committee in Common (‘Committee’) would be amended to include deputations. The Terms of Reference were amended accordingly and approved by the Committee at its meeting on 22nd August 2019. The amendments are highlighted as tracked changes for ease of reference.

Recommendation The Governing Body is asked to review and approve the revised Terms of Reference.


The revisions to the Terms of Reference clarify the rules by which the Committee deals with deputations.


The Terms of Reference set out the arrangements by which the Committee manages conflicts of interest.


Not applicable.

Engagement

This paper was presented to the Committee which includes lay members and clinicians from each of the five NCL CCGs.


This report has been written in accordance with the provisions of the Equality Act 2010.

155155




The revised Terms of Reference were presented to the Committee on 22nd August 2019 and were approved. Previously the Terms of Reference were last reviewed by the Committee on 21st February 2019 and approved by Governing Bodies in March 2019.

Next Steps If the Governing Body approved the revised Terms of Reference the next step is to put them into operation.

Appendices

None.

156156

NCL Primary Care Commissioning Committee in Common

Terms of Reference

1. Introduction 1.1 In 2017 the five Clinical Commissioning Groups (‘CCGs’) within North Central London

(‘NCL’) agreed to work together in exercising Primary Care commissioning functions, as delegated to the CCGs by NHS England under 13Z of the National Health Service Act 2006 (as amended) (‘NHS Act 2006’).

1.2 The five NCL CCGs are:

NHS Barnet CCG; NHS Camden CCG; NHS Enfield CCG; NHS Haringey CCG; and NHS Islington CCG.

1.3 In accordance with its statutory powers under section 13Z of the National Health

Service Act 2006 (as amended) (‘NHS Act 2006’), NHS England subsequently delegated the exercise of the functions specified in section 4 below to each of the NCL CCGs for their own geographical areas.

1.4 Each CCG has established its own individual Primary Care Commissioning Committee

as a committee of its Governing Body. The purpose of each committee is to be a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers.

1.5 To promote cross NCL understanding, collaborative and integrated working,

information sharing, benchmarking, greater transparency, openness and help manage conflicts of interest each of the NCL CCGs have agreed to hold their Primary Care Commissioning Committee meetings in the same time, in the same place, as a committee in common with a common Terms of Reference. This committee in common is known as the NCL Primary Care Commissioning Committee (‘Committee’).

1.6 These Terms of Reference set out the membership, remit, responsibilities and

reporting arrangements of the Committee. 2. Committees in Common 2.1 The following form the Committee:

NHS Barnet CCG Primary Care Commissioning Committee; NHS Camden CCG Primary Care Commissioning Committee; NHS Enfield CCG Primary Care Commissioning Committee; NHS Haringey CCG Primary Care Commissioning Committee; NHS Islington CCG Primary Care Commissioning Committee.

3. Statutory Framework 3.1 NHS England has delegated to each of the NCL CCGs the authority to exercise the

primary care commissioning functions set out in section 4 below for their own geographical areas in accordance with section 13Z of the NHS Act 2006.

157157

3.2 Arrangements made under section 13Z of the NHS Act 2006 may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and each CCG.

3.3 Arrangements made under section 13Z of the NHS Act 2006 do not affect the liability

of NHS England for the exercise of its functions. However, each CCG acknowledges that in exercising its functions (including those delegated to it) it must comply with the statutory duties set out in Chapter A2 of the NHS Act 2006 including:

No. Statutory Duty Section of NHS Act 2006 1. Management of Conflicts of Interest 14O 2. Duty to promote the NHS Constitution 14P 3. Duty to exercise its functions effectively, efficiently

and economically 14Q

4. Duty as to improvement in quality of services 14R 5. Duty in relation to quality of primary medical

services 14S

6. Duties as to reducing inequalities 14T 7. Duty to promote the involvement of each patients 14U 8. Duty as to patient choice 14V 9. Duty as to promoting integration 14Z1 10. Public involvement and consultation 14Z2

3.4 In respect of the delegated functions from NHS England, the CCG will need to exercise

those functions in accordance with the relevant provisions of section 13 of the NHS Act 2006 including:

No. Statutory Duty Section of NHS Act 2006 1. Duty to have regard to impact on services in certain

areas 13O

2. Duty as respects variation in provision of health services

13P

3.5 Each of the individual Primary Care Commissioning Committees which form the

Committee is established by their respective Governing Bodies in accordance with Schedule 1A of the NHS Act 2006.

3.6 The members of the Committee acknowledge that the Committee is subject to any

directions made by NHS England or by the Secretary of State. 4. Role of the Committee 4.1 The role of the Committee is to carry out the function relating to the commissioning of

primary medical services under section 83 of the NHS Act 2006. This includes the following:

Decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: o Decisions in relation to Enhanced Services; o Decisions in relation to Local Incentive Schemes (including the design of

such schemes) o Decisions in relation to the establishment of new GP practices (including

branch surgeries) and closure of GP practices; o Decisions about ‘discretionary’ payments;

158158

o Decisions about commissioning urgent care (including home visits as required) for out of area registered patients;

o The approval of practice mergers; o Planning primary medical care services in the area, including carrying out

needs assessments; o Undertaking reviews of primary medical care services; o Decisions in relation to the management of poorly performing GP practices

and including, without limitation, 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);

o Management of delegated funds; o Premises costs directions functions; o Co-ordinating a common approach to the commissioning of primary care

services with other commissioners in NCL where appropriate; and o Such other ancillary activities that are necessary in order to exercise the

Delegated Functions. 4.2 In performing its role the Committee will exercise its management of the functions in

accordance with the Delegation and the Delegation Agreement that each CCG entered into with NHS England. The Delegation and the Delegation Agreement sit alongside these Terms of Reference.

4.3 The functions of the Committee are undertaken in the context of a desire to promote

increased co-commissioning to increase quality, efficiency, productivity, value for money and remove administrative barriers.

4.4 The Committee will have due regard to any relevant Quality and Safety issues which

may arise as agreed by Committee members. 4.5 In performing its role each Primary Care Commissioning Committee will act within the

powers delegated to it by NHS England. 4.6 Decisions made by each individual Primary Care Commissioning Committee will be

binding on NHS England as long as decisions are made within the scope of the powers delegated to it.

4.7 In performing its role Committee members will act in good faith towards each other,

work collaboratively, review evidence, share information, provide objective expert input and endeavour to reach a consensus and collective view.

5. Geographical Coverage 5.1 Each individual CCG is the decision maker and has responsibility for carrying out the

functions for their own geographical areas as set out below: Committee Geographical Area NHS Barnet CCG Primary Care

Commissioning Committee London Borough of Barnet

NHS Camden CCG Primary Care Commissioning Committee

London Borough of Camden

NHS Enfield CCG Primary Care Commissioning Committee

London Borough of Enfield

NHS Haringey CCG Primary Care Commissioning Committee

London Borough of Haringey

159159

NHS Islington CCG Primary Care Commissioning Committee

London Borough of Islington

6. No Double Delegation 6.1 The Committee operates under the principle of no double delegation. This means that

each CCG may only carry out the functions and make decisions for its own geographical area. No CCG has the power or authority to carry out the functions or make decisions for other any other CCG or its geographical area.

7. Pooling Budgets 7.1 The individual CCG Primary Care Commissioning Committees comprising the

Committee have no authority to pool budgets with each other. 7.2 Each individual CCG Primary Care Commissioning Committee is responsible for the

delegated funds in their respective geographical areas. 8. Membership 8.1 The membership of each of the individual Primary Care Commissioning Committees

will meet the requirement of their respective Constitutions. 8.2 The Committee and each of the individual Primary Care Commissioning Committees

shall have a lay and executive majority. 8.3 The Committee shall have the following non-voting attendees who will sit at non-voting

attendees in common across all five NCL Primary Care Commissioning Committees: A Practice Nurse representative; NHS England representative(s); Health and Wellbeing Board representative(s); Healthwatch Representative(s); LMC Representative(s); An NCL CCG Director of Quality; Non-conflicted external clinicians.

8.4 The list of members and non-voting attendees is set out in Schedule 1. Schedule 1

does not form part of these Terms of Reference and may be amended or updated without the need to formally amend the Terms of Reference.

8.5 Committee members may nominate deputies to represent them in their absence and

make decisions on their behalf. Non-voting attendees may nominate deputies to represent them in their absence.

8.6 The Committee may call additional experts to attend meetings on a case by case basis

to inform discussion. 8.7 The Committee may invite or allow additional people to attend meetings as attendees.

Attendees may present at Committee meetings and contribute to the relevant Committee discussions but are not allowed to participate in any formal vote.

8.8 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.

160160

9. Chair and Vice Chair of the Committee 9.1 The Chair of the Committee shall be a Lay Member from an NCL CCG. The Committee

Chair shall not be the Chair of an NCL CCG Audit Committee nor a Conflict of Interest Guardian.

9.2 The Vice Chair of the Committee shall be a Lay Member from an NCL CCG. The

Committee Vice Chair shall not be the Chair of an NCL CCG Audit Committee nor a Conflict of Interest Guardian.

10. Voting 10.1 Each individual Primary Care Commissioning Committee shall vote and make

decisions for their own geographical area only. A vote of one Primary Care Commissioning Committee will not be binding on any other Primary Care Commissioning Committee.

10.2 Each voting member of each Primary Care Commissioning Committee shall have one

vote with resolutions passing by simple majority. 10.3 Each Primary Care Commissioning Committee shall nominate a Lay Member from its

own CCG to have the casting vote. 10.4 The Chair of the Committee may not vote on any resolution other than on those

resolutions from his or her own CCG’s geographical area. 10.5 The Vice Chair of the Committee may not vote on any resolution other than on those

resolutions from his or her own CCG’s geographical area. 10.6 Where there is a pan NCL resolution each of the five individual Primary Care

Commissioning Committees must vote in favour of the resolution for it to pass. 10.7 Each individual Primary Care Commissioning Committee can only invest their own

delegated funds in their own geographic area. However, where there are new or additional funds available that are not delegated funds such as new transformation monies all decisions on how such money is invested will be treated as a pan NCL resolution.

11. Decisions 11.1 The Committee and each individual NCL Primary Care Commissioning Committee will

make decisions within the bounds of their remit. 11.2 Decisions of the Committee and each individual Primary Care Commissioning

Committee will be binding on NHS England as long as decisions are made within the scope of the powers delegated.

11.3 Due to the nature of primary care commissioning the Committee recognises that some

urgent and immediate decisions may need to be made outside of Committee meetings. Each individual NCL Primary Care Commissioning Committee may therefore delegate urgent and immediate decisions that need to be made outside of Committee timescales in accordance with clauses 11.4 – 11.5 and 11.8 below.

161161

11.4 Urgent decisions requiring a response within 24 hours will be made collectively by the

following people or their nominated deputies: The relevant Chair of the CCG; The relevant CCG Chief Operating Officer or NCL Director of Planning

Performance and Primary Care; The relevant CCG lay representative.

11.5 Immediate decisions requiring a response within 2 weeks will be made at a Committee

meeting where practicable. Where this is not practicable the following people or their nominated deputies will collectively make the decision:

The relevant Chair of the CCG; The relevant CCG Chief Operating Officer or NCL Director of Planning

Performance and Primary Care The relevant CCG lay representative.

11.6 Due to the nature of primary care commissioning the Committee recognises that the

following non-contentious, low risk, decisions may be made outside of Committee meetings by those listed in clause 11.7 below: :

Requests to add or remove a partner; Retirement of a partner and adding of a new partner; Partnership changes- 24 hour retirement; Opening of a patient list; Increases in practice boundaries.

11.7 The following people or their nominated deputies may collectively make the non-

contentious, low risk decisions set out in clause 11.6 above: The relevant CCG lay representative; The relevant CCG clinician; The NCL Director of Planning Performance and Primary Care.

11.8 Decisions made outside of Committee meetings will be reported to the Committee at

the next Committee meeting. This may be in a public or private part of the meeting depending on the nature of the business and the decision(s) made.

12. Quorum 12.1 Each individual Primary Care Commissioning Committee must have a lay and

executive majority to be quorate. The following members must also be present: One lay representative; One officer representative; One clinical representative.

12.2 If the clinical representative referred to in clause 12.1 above is conflicted on a particular

item of business they will not count towards the quorum for that item of business and a non-conflicted clinician will be appointed or co-opted in their place.

12.3 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 to satisfy the quorum requirements.

162162

12.4 For the Committee to be quorate all five individual Primary Care Commissioning Committees must be quorate. If a Committee meeting is not quorate the Chair may permit the appointment or co-option of additional members if necessary.

12.5 In some very rare circumstances all clinicians may be conflicted and therefore it may

not be possible to co-opt or appoint a non-conflicted clinician to satisfy the quorum requirements. In this case the Chair may dis-apply the requirement to have a clinical representative present in clause 12.1 above and deem the meeting quorate upon the agreement of all of the lay representatives on the Committee.

13. Secretariat 13.1 The Secretariat to the Committee shall be provided by the NCL Corporate Services

Team. 14. Frequency of Meetings 14.1 The Committee shall meet bimonthly or as otherwise agreed by the Committee. 15. Notice of Meetings 15.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7

days in advance of the meeting. 15.2 The meeting shall contain the date, time and location of the meeting. 15.3 Where Committee meetings are to be held in public the date, times and location of the

meetings will be published on each CCG’s website. 16. Agendas and Circulation of Papers 16.1 Before each Committee meeting an agenda setting out the business of the meeting

will be sent to every Committee member no less than 7 days in advance of the meeting. 16.2 Before each Committee meeting the papers of the meeting will be sent to every

Committee member no less than 7 days in advance of the meeting. 16.3 If a Committee member wishes to include an item on the agenda they must notify the

Chair via the 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.

17. Minutes and Reporting 17.1 The minutes of the proceedings of a meeting shall be prepared by the Secretariat and

submitted for agreement at the following Committee meeting. 17.2 The approved minutes will be presented to the NHS England area team. They will also

be presented to each individual NCL CCG Governing Body as per their local requirements.

17.3 Each individual CCG will comply with their own Governing Body’s reporting

requirements. 18. Conflicts of Interest

163163

18.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed by each of the NCL CCGs together with a schedule setting out each CCG’s local variations to that policy.

18.2 Each CCG shall ensure appropriate local safeguards are in place to maintain the

integrity of the role of Conflicts of Interest Guardian. 18.3 The Committee shall have a Declarations of Interest Register that will be presented as

a standing item on the Committee’s agenda. In addition, an opportunity to declare any new or relevant declarations of interest will be listed as a standing item on the Committee’s agenda

19. Gifts and Hospitality 19.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest

Policy and NHS England statutory guidance for managing conflicts of interest. 19.2 The Committee shall have a Gifts and Hospitality Register that will be presented as a

standing item on the Committee’s agenda. In addition, an opportunity to declare any new or relevant declarations of relevant gifts and hospitality will be listed as a standing item on the Committee’s agenda

20. Meetings Held in Public 20.1 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 in part, may be held in private. The Committee may also exclude non-voting attendees and observers. Meetings or parts of meetings held in public will be referred to as ‘Meeting Part 1’. Meetings or parts of meetings held in private will be referred to as ‘Meeting Part 2.’

20.2 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:

The confidential nature of the business to be transacted; or The matter is commercially sensitive or confidential; or The matter being discussed is part of an on-going investigation; or The matter to be discussed contains information about individual patients or

other individuals which includes sensitive personal data; or Information in respect of which a claim to legal professional privilege could

be maintained in legal proceedings is to be discussed; 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 To allow the meeting to proceed without interruption, disruption and/or general

disturbance. 21. Questions from the Public and Deputations

21.1 The Committee may receive questions from the public at its absolute discretion in line

with the CCGs’ protocol for public questions which is available on the CCGs’ websites.

Formatted: Indent: First line: 0 cm

Formatted: Indent: Left: 0 cm, Hanging: 1.27 cm

164164

21.2 The Committee may receive, at its absolute discretion, Deputations from members of

the public or interested parties to make the Committee aware of a particular concern or concerns they have.

21.3 Any Deputations should be sent to the Committee secretariat who will pass it to the

Chair and to the Lay Member for the CCG to which the Deputation relates for consideration.

21.4 Any Deputations must be received by the Committee secretariat at least three working

days before a Committee meeting is due to take place to be eligible to be heard at that Committee meeting. However, where it is not possible to comply with this deadline due to the papers of the meeting being published later or due to a public holiday the Deputations must be submitted within a reasonable time.

21.5 Any Deputations not received within this time will not be eligible to be heard at that

Committee meeting. However, on a strictly case by case basis there may be times where it would be highly beneficial to the Committee’s business to waive this requirement due to the relevance or content of the Deputations. In these circumstances the Chair acting with the relevant Lay Member may do so on a case by case basis and without setting any precedents of future or further waivers.

21.6 Any Deputations must take the form of a written request together with a statement

setting out what the Deputation is about. If any Deputation fails to set out this information it will be rejected.

21.7 Any Deputations which are not relevant to the Committee’s business will be rejected

21.8 The Chair acting with the relevant Lay Member may accept or reject any relevant and

properly completed Deputations on a strictly case by case basis at his/her absolute discretion and without setting any precedents for future or further decisions.

21.9 If a request is agreed the interested party and/or parties will be invited to a Committee

meeting where the Committee will consider the Deputation.

21.10 The Chair acting with the relevant Lay Member may decide how much time to allocate to any Deputations at his/her absolute discretion on a case by case basis and without setting any precedents for future or further decisions on time allocated for Deputations.

21.11 Nothing in this section 21 shall limit, prohibit or otherwise restrict the Committee’s

powers contained in section 8, 20 or 22 of these Terms of Reference. 21.12 Where the Deputation relates to business to be decided by the Chair’s own CCG’s

geographical area only the requirement for the Chair to act with another Lay Member as set out in sections 21.3, 21.5, 21.8 and 21.10 does not apply.

221. Confidentiality 221.1 Members of the Committee shall respect the confidentiality requirements set out in

these Terms of Reference unless separate confidentiality requirements are set out for the Committee in which event these shall be observed.

221.2 Committee meetings may in whole or in part be held in private as per section 20 above.

Any papers relating to these agenda items will be excluded from the public domain. For any meeting or any part of a meeting held in private all members and/or attendees






Formatted: Indent: First line: 0 cm





Formatted: Highlight

Formatted: Indent: Left: 0 cm, First line: 0 cm

165165

must treat the contents of the meeting and any relevant papers as strictly private and confidential.

221.3 Decisions of the Committee will be published by Committee members except where

matters under consideration or when decisions have been made in private and so excluded from the public domain in accordance with section 20 above.

232. Standards of Business Conduct 232.1 Committee members, attendees and/or observers must maintain the highest standards

of personal conduct and in this regard must comply with: The law of England and Wales; The NHS Constitution; The Nolan Principles; The standards of behaviour set out in each NCL CCG Constitution; Any additional regulations or codes of practice relevant to the Committee.

243. Training and Information 243.1 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.

254. Sub-Committees 254.1 The Committee and each individual Primary Care Commissioning Committee may not

delegate any of its powers to a committee or sub-committee but it may appoint sub-committees and/or working groups to advise and assist it in carrying out its functions.

254.2 Any sub-committees or working groups must abide by the NCL Conflicts of Interest

Policy and NHS England statutory guidance for managing conflicts of interest. 265. Review of Terms of Reference 265.1 These Terms of Reference will be reviewed from time to time, reflecting experience of

the Committee in fulfilling its functions and the wider experience of CCGs in primary care commissioning.

265.2 These Terms of Reference will be formally reviewed in April each year following the

establishment of the Committee. These Terms of Reference may be changed or amended by mutual agreement of the Committee and on being approved by each of the Governing Bodies of the NCL CCG’s in accordance with their Constitutions.

166166

Schedule 1 - List of Members This schedule sets out the membership, attendees, Chair and Vice Chair of each individual Primary Care Commissioning Committee and the Committee.

NHS Barnet Primary Care Commissioning Committee The voting members of the NHS Barnet Primary Care Commissioning Committee are as follows: Position Name Title Clinical representative Dr Murtaza Khanbhai Governing Body GP

Representative Lay representative

Mr Ian Bretman Lay Member

Officer representative Ms Colette Wood Director of Care Closer to Home

Member with casting vote

Mr Ian Bretman Lay Member

NHS Camden Primary Care Commissioning Committee The voting members of the NHS Camden Primary Care Commissioning Committee are as follows: Position Name Title Clinical representative Dr Kevan Ritchie Governing Body GP

Representative Lay representative Ms Glenys Thornton Lay Member Officer representative Ms Sarah McDonnell-

Davies Director of Primary and Community Care / Deputy Chief Operating Officer

Member with casting vote Ms Glenys Thornton Lay Member

NHS Enfield Primary Care Commissioning Committee The voting members of the NHS Enfield Primary Care Commissioning Committee are as follows: Position Name Title Clinical representative Dr Mateen Jiwani Governing Body GP

Representative Lay representative

Ms Karen Trew Lay Member

Officer representative

Ms Deborah McBeal Director of Primary Care Commissioning / Deputy Chief Officer

Member with casting vote

Ms Karen Trew Lay Member

NHS Haringey Primary Care Commissioning Committee

167167

The voting members of the NHS Haringey Primary Care Commissioning Committee are as follows: Position Name Title Clinical representative Dr Dina Dhorajiwala Governing Body GP

Representative Lay representative Ms Cathy Herman Lay Member Officer representative Ms Rachel Lissauer Director of Commissioning Member with casting vote Ms Cathy Herman Lay Member for Public and

Patient Engagement and CCG Vice Chair (Non-Clinical)

NHS Islington Primary Care Commissioning Committee The voting members of the NHS Islington Primary Care Commissioning Committee are as follows: Position Name Title Clinical representative Dr Dominic Roberts Clinical Director, GP

Representative Lay representative Ms Sorrel Brookes Lay Member Officer representative Ms Clare Henderson Director of Commissioning Member with casting vote Ms Sorrel Brookes Lay Member

Non-Voting Attendees The following non-voting attendees sit as non-voting attendees on all of the NCL Primary Care Co-Commissioning Committees as attendees in common:

Position Name Title

Practice Nurse representative Ms Charlotte Cooley Practice Nurse Representative

Health and Wellbeing Board representative(s)

TBC

Healthwatch representative(s) Ms Emma Whitby Chief Executive, Islington Healthwatch

LMC Representative Mr Greg Cairns Director of Primary Care Strategy

LMC Representative Dr Manish Kumar Chair, Enfield LMC

NHS England Representative Ms Anne Whateley Director Primary Care Commissioning and Transformation

NCL CCG Director of Quality Ms Neeshma Shah Director of Quality & Clinical Effectiveness, Camden CCG

External Clinician TBC TBC

168168



The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ 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 in Common The Chair and Vice Chair of the Committee are as follows: Position Name Title CCG

Geographical Area

Chair Ms Cathy Herman (from Haringey CCG)

Lay Member for Public and Patient Engagement and CCG Vice Chair (Non-Clinical)

Haringey

Vice Chair Ms Sorrel

Brookes Lay Member for Public and Patient Engagement

Islington

169169

170170

Barnet Clinical Commissioning Group Governing Body 19 September 2019

Report Title Quality and Performance Report Agenda Item 4.3


Dr Barry Subel Tel/Email [email protected]


Jenny Goodridge, Director of Quality and Clinical Services Ali Malik, Director of QIPP, Planning and Performance

Tel/Email [email protected] [email protected]

Report Author

Swetlana Wolf, Deputy Director of Quality and Clinical Services Ali Malik, Director of QIPP, Planning and Performance.

Tel/Email [email protected] [email protected]

Report Summary This report provides an overview of performance and quality issues since the

last report to the Governing Body on 20 June 2019.

Recommendation To note the contents of this report and the actions that are in place working

with our providers to improve performance and quality of care for patients.


Risks as identified within the report. In addition, there is a specific risk on the GBAF (GBAF 21) in relation to potential quality and patient safety concerns at the Royal Free London.


Not applicable


Not applicable

Engagement

Not applicable


Not applicable


Last presented to Governing Body in March 2019

Next Steps To continue to monitor the performance and quality of the services commissioned by Barnet CCG and highlight any concerns/hot topics to the Governing Body.

Appendices Not applicable

171171






172172

Quality & Performance ReportQuality & Performance Committee August 2019

Lead Directors: Jenny GoodridgeDirector of Quality & Clinical ServicesAli Malik Director of QIPP, Planning and Performance

173173

2

Note: Acute performance and quality is monitored through North Central London’s Joint Commissioning Committee – latest performance report can be found here: http://www.barnetccg.nhs.uk/about-us/NCL-joint-commissioning-committee.htm. A summary of the key acute performance and quality measures is noted below.

Royal Free London (RFL) Care Quality Commission (CQC) reportFollowing the CQC inspection in December 2018 and January 2019 after which the Trust was rated ‘Requires Improvement’ overall, the Trust was issued with an improvement notice with 11 “Must do” actions and 82 “Should do” actions. The Trust has shared the action plan for the “Must Do” actions with the Clinical Quality Review Group (CQRG), which is monitoring delivery of the plan. Most of the issues identified for improvement by the CQC have been areas that the trust and the CCG have been working on together over the past year. For example, the ‘culture of bullying’ was a theme that became apparent during the review of some of the Never Events that occurred in 2017 and 2018. In addition to following organisational Human Resources policies to manage bullying, the Trust have undertaken a number of actions to address this issue, including:• Increasing the number of ‘speak up’ champions in order to provide staff with a safe opportunity to raise concerns• Multi-disciplinary safety huddles in theatres• Dedicated staff listening sessions in the top 5 areas where bullying and harassment is reported as per the staff survey results• Dedicated bullying and harassment group that feeds into the People Committee• Bullying and harassment videos shared at staff network meetings and individuals are encouraged to speak up where they

experience or see behaviour which could be considered to be bullying and harassment• ‘Joy in work’ improvement collaborative bullying and harassment quality improvement project underway - a different approach

to improving behaviours in teams• Ongoing development to embed Values and Behaviours

The CQC improvement plan is monitored through the Clinical Quality Review Group.

Executive Summary Acute – Quality and Performance

174174

http://www.barnetccg.nhs.uk/about-us/NCL-joint-commissioning-committee.htm

3

Royal Free London (RFL) System escalation updateA system-wide meeting involving the RFL, Barnet CCG, NHS England/Improvement (NHSE/I), Health Education England and the General Medical Council took place on 15 July 2019. The CQC were not in attendance, but NHSE/I fed back that the CQC were not stepping up the Trust surveillance and would continue to monitor progress with the implementation of the CQC recommended actions through the usual regular meetings they had with the Trust.Partners at the meeting expressed that they felt there was no longer a need for system-wide enhanced surveillance of the Trust at present and would revert to standard monitoring. BCCG will continue to monitor through the CQRG and refer back to regulators ifnecessary.

Serious Incidents / Never events - Two never events (NEs) have been reported: one misplaced nasogastric tube in May 2019 and one transfusion of ABO-incompatible blood components to the wrong patient in July 2019. The Trust are investigating these NEs and will be working with commissioners to implement any learning identified as a result of these events.

There has been a reduction in overdue Serious Incidents (SIs) from the last report. There are now 13 overdue, compared with 27 in April 2019, and 36 open SIs overall. The Trust continues to apply a risk-grading approach to managing the investigation of overdue SIs

Pathology issues and waits - GP concerns relating to Pathology services at RFL/HSL are still being reported. The numbers have been decreasing and are mainly related to system issues. Commissioners and GPs are meeting regularly with the Trust and laboratory representatives to monitor the action plans to improve the service. Some issues have been resolved. A set of Key Performance Indicators are being put in place to monitor the turnaround times for pathology tests.RFL has been experiencing a large increase in demand on their phlebotomy since January 2019. To mitigate this, RFL will be rolling out a booking system with some walk-in capability in order to manage capacity as well as allow for urgent testing. The Trust are considering an appointment-only system at the RFH site to manage flow better. There are also plans to have a walk-in clinicat Barnet Hospital and urgent recruitment for phlebotomists is currently underway. The CCG has requested an ideal capacity modelling and implementation plan to be submitted so Barnet CCG can monitor RFL progress against plan.


175175

4

Royal Free London (RFL) Cancer – Performance against the 62 day standard has fallen for the CCG to 81.1% in May 2019 (from 87.7% in April). Two week wait performance has improved to 90.3% (from 89.3% in April). Both standards remain below target. Royal Free London are addressing issues relating to histopathology reporting delays by implementing improvements to the lower gastro-intestinal pathway and increasing the proportion of patients triaged straight to endoscopy. These improvements are being seen in the 62 day backlog performance, which has seen decreases in recent weeks. As of 7 July 2019, the 62 day backlog at Royal Free London stood at 116 (falling from 155 in mid-June). Roll-out of Faecal Immunochemical Test (FIT) across NCL from 1 April 2019 is helping to further improve performance by releasing endoscopy capacity.

RFL had a further Cancer Clinical Practice Group (CPG) day in June. This day concentrated on cancer patient experience. Therewere sessions on running effective Multi-Disciplinary Teams (MDT) with examples of patient experience, patient research and bestpractice from Bart’s. RFL invited patients and stakeholders along to the day to present their points of view to attendees.

At the July 2019 CQRG, RFL will be presenting an update on the CPG initiatives; quality improvements on Root Cause Analysis reporting; Cancer Outcomes and Services Dataset (staging) and their updated Patient Experience action plan. Accident and Emergency (A&E) – The Royal Free London four hour A&E performance remained steady at 86.1% in June 2019 as it was in May. However, performance challenges are ongoing with particular issues associated with bed occupancy levels, and Emergency Department (ED) workforce capacity and increased attendances. At Barnet Hospital, the Urgent Treatment Centre project is progressing, supported by commissioners. An option to deliver a spacewithin revised capital funding is being assessed and a drafted business case to be reviewed. Barnet Hospital and Barnet CCG have agreed a plan to be developed with system partners to ease bed capacity issues. ED medical and nursing workforce plans have been drafted and e-Rosters are being implemented for medical staff during Q2 2019/20.The Royal Free Hospital is supporting a front door ambulance challenge with system partners and London Ambulance to identify blocks and areas of opportunity. Work is in progress to increase hours of administration support and proposal to fund appropriate clinical rotas to cover Rapid Access Treatment. They are proposing an increase in middle grade cover and establishing a full time permanent consultant leading paediatric ED and recruitment plans are in place for nursing vacancies. Acute Assessment Unit chairs have been converted to bedded ward capacity, and the Mental Health team is attending daily SitRep meetings in ED to improve escalation process.


176176


5

Royal Free London (RFL) Referral to Treatment (RTT) – Barnet CCG did not achieve the standard in May, with performance at 87.8%. Please note this performance is without Royal Free RTT data – the Royal Free has suspended RTT reporting until further notice. Excluding patientswaiting at the Royal Free, there were 11,654 incomplete waiters. This is down from 11,712 in April. Some specialties are achieving the standard, namely Cardiothoracic Surgery, Geriatric Medicine, Ophthalmology, and Thoracic Medicine. As mentioned, The Royal Free Trust board, in agreement with regulators, has decided to cease Referral to Treatment reporting until assurance of the data is confirmed. This will have a significant impact on our reporting, and we are working with NCL colleagues and NHS England to assess impact and reset any trajectories/plans. The Trust has procured a data validation tool fromMBI Health called LUNA, which will help to create a priority tracking list for operational use, assist data validation and enable reporting for the overall management of elective care. The Trust now has a validation exercise in progress to compile a more robust patient list and reduce anomalies. A validation team has now been recruited and begun the exercise. Regular Trust meetings with Barnet CCG, as well as NHS England/Improvement, are now in place to provide updates and assurance. In the meantime, we are working closely with the Trust to maintain oversight on waiting times, to establish secondary monitoring protocols and to provide assurance and ensure long waiters are still properly managed. Capacity constraints have been identified in urology, dermatology, plastic surgery, upper gastro intestinal (Hepato-PancreatoBiliary), pain management, trauma & orthopaedics and general surgery. Recovery action plans are in place for these specialties and these are reviewed at monthly meetings.There were 57 harm reviews undertaken in March 2019. All were assessed as low harm with no moderate or severe harm cases. The low harm themes were for plastic surgery, pain management and orthopaedics. Central London Community Healthcare (CLCH) After initial delays due to CLCH staffing issues, the process of reviewing the quality of children’s services has commenced at the CLCH Clinical Quality Review Group in June 2019. This was previously managed through the Joint Children’s Unit which ended in November 2018.

177177

Non-acute: quality and performance

6178178

Community & Children (CLCH)

7

Non-Consultant led services 6 week wait• CLCH has sustained national RTT performance so far in 2019/20, but Podiatric

surgery is still underperforming. Remedial actions, such as additional clinic and theatre capacity, are in progress and 52 week waiters are down to 3 patients. A zero 52 week wait trajectory has been agreed for achievement in Sept 2019, and an 18 week trajectory to Dec 2019.

• Intermediate care (uni and multi-therapy input) is underperforming and a Remedial Action Plan (RAP) has been submitted. The trajectory for compliance is to Oct 2019. Vacancies, a consequence of the transformation of the unplanned & planned care teams, are being addressed, along with caseload reviews and a cap on visits per patient per day.

• MSK physio failed their trajectory for re-compliance due to loss of staffing capacity.• Podiatry met target in May 2019.• Speech and Language Therapy (SLT) met target in May 2019. Longer waits

within Parkinson SLT noted; action plan and recovery trajectory is in place.

• Orthotics and Children's eye screening form part of the 19/20 Service Development & Improvement Plans (SDIP). Commissioners will look at the cost & volume of appliances. A business case for eye screening is in development to include a revised pathway for marginal fails of eye screening and will include provision of the ophthalmologist currently provided by RFL.

• Commissioners issued an Information Breach Notice in May 2019 for failure to rectify data errors highlighted by NEL CSU - a recovery plan is on track due to complete by Sept 2019 and will include revision of 2018/19 and Year To Date (YTD) data.

Key points to note

• Monthly review of Podiatric surgery RAP and trajectory performance via Contract Management Group.

• Commissioners in discussion with CLCH to deliver a new specification for the whole of MSK (an integrated model). Commissioners, however, may decide to issue a performance notice for the current physio service for not meeting the 6 week wait.

• The Continence service is also underperforming against 6 weeks waiting times - a RAP has been requested, due in Aug 2019.

• The SDIP is tracked via the Contract Technical Meeting - a milestone tracker is in place.

Actions / next steps

Consultant led services 18 week wait (Adults)

Current Performance M2 2019/20

Service Line 01/04/2019 01/05/2019Continence Service 74.67% 69.01%ICUD 70.84% 61.89%ICMD 74.17% 85.71%ICSLT 83.02% 96.97%MSK Physio 72.65% 69.04%Nutrition and Dietetics 86.84% 91.21%Podiatry 90.69% 95.79%Respiratory/Spirometry 58.82% 46.49%Stoma Care #N/A 100.00%Tissue Viability 95.74% 97.92%Orthotics 81.63% 82.93%Children's Orthoptics 70.05% 71.52%

Service Line 01/04/2019 01/05/2019

Diabetes - Barnet 94.80% 95.45%Falls 100.00% 99.32%

Heart Function 100.00% 100.00%ICMSK 99.57% 99.84%

Parkinson's Service 95.00% 96.92%Podiatric Surgery 44.00% 55.70%

Respiratory/COPD 100.00% 98.05%

Trendline

Trendline

179179

8

Royal Free London – Community paediatric servicesAn Autistic Spectrum Disorder (ASD) business case is going to the Senior Management Team in July to implement a waiting list initiative with Royal Free London. If approved through CCG governance, it is expected that from the point of approval it will take six months to clear the waiting list. CCG-led ASD Strategic Group set up with representation from providers, Local Authority (social care, education) and Barnet Parent Carer Forum. The first meeting took place on 2 July 2019 to start reviewing the whole ASD pathway, including pre-diagnostic/referrals, diagnostic process and post-diagnostic support to ensure NICE compliance and delivery of a supportive, efficient pathway. Commissioners are also working with NCL colleagues to share best practice. OptegraThe service is receiving early positive patient feedback and minimal complaints. CQC improvement plan is being monitored at contractual meetings. Activity remains lower than expected which is being explored by the CCG. Training opportunities are being discussed with Health Education England.Gynaecology Partnership Limited (provider of the community gynaecology service)The CCG management of this contract from 2019/20 onwards has successfully transferred between the Urgent and Emergency Care (UEC) team to the Planned Care team. The providers’ proposal of a Barnet Community Gynaecology Service rapid access hysteroscopy service was approved at April 2019 Programme Oversight and Delivery Group (PODG) and the service is ready to go live. Commissioners continue to work with the provider on optimising the reporting of key performance quality indicators which now include numerical values next to progress as well as additional KPIs regarding the number of complaints, incidents, Serious Incidents (SIs) received as well as referrals to cancer MDTs. No complaints, incidents or SIs have been received in the last quarter and the service continues to be well used and receives good patient feedback. A contract and contract variation for the current service has been signed. Integrated Wheelchair Services (AJM Healthcare) – NHS West London Clinical Commissioning Group is the Co-ordinating Commissioner There have been no complaints recorded. The KPI for the personal wheelchair budgets is now included as a part of the standard monthly reporting.

Key points to note

Small Contracts: Quality update

180180

9

Cricklewood Walk in Centre (WiC)

A contract and & Quality meeting was held in June and the provider reported seven incidents from Q2 – Q4 2018/19. None were serious incidents and no harm came to patients or staff involved. Three formal complaints were made from May 2018 - April 2019. One complaint was upheld and two were not upheld. No compliments were receiving in the reporting period.

Provider ability for recording ethnicity remains an area of underperformance. It is anticipated that this will be Green for June performance data.

Workforce - Barndoc are yet to recruit an additional GP and are currently working with a Locum. The provider confirmed the WiCis fully staffed and is managing its demand so there are no concerns.

The Cricklewood WiC consultation will commence 29 July 2019 for 12 weeks on a proposal to decommission the WiC.

Inhealth NCL Diagnosis - NHS Camden is the co-ordinating Commissioner

The last contract review meeting took place on 5 June 2019. The service continues to meet their KPI turnaround times, however, there was a slight breach in echocardiography 20 working day investigation time due to capacity which is being investigated. It is likely due to the service overall workforce challenge to recruit to radiographer and sonographer posts which is being addressed. It was also noted that one SI was reported in Q4 for Barnet (of two SIs for NCL as a whole): Incorrect booking and scanning of obstetric patient within the non-obstetric scanning service. An internal investigation is in progress. In terms of patient experience, the Friends and Family Test satisfaction results continues to be high.

In addition, there has been a rise in MRI and Ultrasound referrals into the service in 2018/19 which the commissioner has been looking into and it is likely due to the general trend in primary care toward direct access diagnostic and care closer to home and this is also being seen in the direct access diagnostic referrals into the Royal Free London Trust.

The current contract with InHealth has been extended from June 2019 to March 2020 to allow for the NCL-wide procurement process which is currently taking place. Few changes to the current service specification are planned, except for some improvements in tariff and referral times.

Key points to note


181181

10

North East London Foundation Trust (NELFT) – integrated children’s therapies Performance/Quality –the following areas were noted at Q1 2019/20 mid-point contract meeting: • Waiting times standards, with the aim of rectifying data accuracy issues and ensuring reported waiting times meet the standards

set for the provider• Waiting times for Education, Health and Care Plan (EHCP) assessmentThe Q1 2019/20 mid-point contract meeting was held on 24 June 2019. Q1 2019/20 contract meeting is scheduled for September 2019. A Contract Performance Notice (CPN) was issued at the Q1 2019/20 mid-point contract meeting, based on the points above. It was agreed with the Trust that this will enable commissioners and the Trust to meet monthly and work jointly on a Remedial Action Plan to resolve key issues ahead of the September contract review meeting.Contract Change Proposal - The Trust provided an update on the new implementation model. It was agreed that the Trust would share the proposal by 28 June; this has been received. The Trust noted that staff consultation has already started and they are working to fully integrate teams in July. On the basis that the proposal is agreed, mobilisation would take a couple of weeks to complete. Discussions are ongoing between London Borough of Barnet, NELFT and Barnet CCG regarding the full mobilisation of the serviceand timescales, with particular focus on handover of private provider provision. EHCP case list validation continues across Education. Issues for special and mainstream schools are being reviewed and development of communication plan with schools. It was agreed at the Q4 2018/19 contract meeting that mobilising the Social Care Occupational Therapy element of the joint Local Authority and CCG contract, would formally be paused to enable the service to focus on the issues above. This will be reviewed at the September Q1 2019/20 contract meeting. North London Hospice (NLH)There have been delays in hiring to consultant roles which is due to negotiations between the Royal Free and NLH around the charging of on-costs for consultant roles. NLH is in discussions with CLCH to host these roles. New service has launched and hasreceived an increase in referrals. NLH has taken part in a series of End of Life meetings with the Barnet GP Clinical Lead of each Primary Care Network to help launch the service with GPs and update them around Coordinate My Care (CMC).Marie Curie Hospice HampsteadContract to be finalised in July 2019. No quality issues to note.

Key points to note


182182

11

Key points to note

Co-commissioned providers: Quality update

Barnet, Enfield and Haringey Mental Health Trust (BEHMHT)

The CQC visit took place 18 – 27 June. The ‘well-led’ inspection is taking place the week commencing 1 July. No warnings or immediate actions were issued by the CQC during the visit. All feedback provided during the visit related to issues that theTrust had already identified:• The CQC raised the issue of bed pressures and out of area placements (a system wide issue) and the need to ensure robust

risk assessment and safety controls.• The Trust continues to report high rates of non-acceptance of CAMHS referrals. The Trust has been asked to review where

these referrals are coming from, why they are inappropriate and ensure that they are being signposted to relevant services.The Trust has an improvement plan in place to address non-compliance with mandatory training. The Trust aims to reach the targets by the end of July and is currently on trajectory to meet this. Basic Life Support (BLS): BLS level 2 (adult) is currently 69%; Basic Life Support level 2 (adult and paediatric) 76% and Intermediate Life Support (ILS) 65%.The Trust is continuing to work on the introduction of trend chart reporting. Run charts have recently been introduced for trustwide reporting, however, this is work in progress with changes required at sub-committee level to support the Board.

Royal National Orthopaedic Hospital (RNOH)

The Serious Incident (SI) deep dive review took place in June 2019. The aim of the deep dive was to provide further scrutiny of the process. Commissioners received further assurance that the SI reporting management was more robust and fit for purpose.Prior to the deep dive, the commissioners shared their key lines of enquiry with the Trust, focussing on patient and family engagement, root cause analysis and shared learning. NHSE/I will be issuing the formal reply and improvement suggestions to the Trust by 31 July 2019.

183183

Mental Health – Improving Access to Psychological Therapies (IAPT)

12

Recovery - Recovery above 50% target has been sustained into 2019/20 (provisional recovery rate performance for May is 50.9%).

Access• BRS delivering IAPT therapies from January 2019.• Additional funding has been committed to Barnet Enfield and Haringey Mental

Health Trust IAPT for Q4 to support reduction to step 2 waiting list. • Additional investment agreed by BCCG to ensure ongoing sustainable

commissioned model in place to deliver IAPT national targets for 2019/20 onwards. Mobilisation of expanded service has begun. Contract modification notice issued.

• Work with Mind in Barnet has begun to support translation of counselling contract to IAPT service provision from Q4 19/20.

• IAPT continues to be an area where we under perform on access but mobilisation to expand the service to ensure access targets are met moving forward are currently occurring.

Out Of Area Placements (OAP)• There were 240 OAP days for Barnet patients in April 2019, down from 500 in

March.• To support Barnet Enfield and Haringey Mental Health Trust to deliver zero

out of area placements by March 2021 (a national ambition), Barnet, Enfield and Haringey CCGs’ proposed an incentive payment scheme that will deliver the 0% target over a two-year period.

This Incentive Payment Scheme, supports and enables Barnet Enfield and Haringey Mental Health Trust to develop and expand community alternatives, reduce average length of stay and avoidable admissions, support more people to remain in their own homes and improve outcomes for adults with mental ill health.

Key points to note

• An IAPT steering group will continue to meet to support improvement and oversight of IAPT service provision.

• Mobilisation of expanded service core provision Q1 2019/20.• Translation of counselling contract to IAPT service provision from Q4 2019/20

with Mind in Barnet.

Actions / next steps

Current Performance

40%

45%

50%

55%

60%

Rec

over

y ra

te

IAPT Recovery Rate Performance

0

100

200

300

400

500

600

700

Acce

ss N

umbe

rs

IAPT Access Performance – Number Entering Treatment

184184

Improvement and Assessment Framework

13

Update on key metrics

185185

Primary Care

14

Metric Data CCG Ranking

RefImprovement and Assessment Framework (IAF) Measures

Target / Standard

LatestPeriod

Jan-19 Apr-19 Jul-19 Trend Jan-19 Apr-19 Jul-19Barnet

CCG rating

Domain

103aDiabetes patients that have achieved all the NICE-recommended treatment targets

2017-18 37.34% 37.3% 37.3% l 138/195 138/195 138/195 GBetter Health

107aAntimicrobial resistance: appropriate prescribing of antibiotics in primary care

0.965 2019 02 0.80 0.79 0.78 18/195 18/195 18/195 GBetter Health

107bAnti-microbial resistance: Appropriate prescribing of broad spectrum antibiotics in primary care

10% 2019 02 12.6% 12.7% 12.7% 192/195 194/195 194/195 RBetter Health

108aThe percentage of carers with a long term condition who feel supported to manage their condition

1 2018 0.52 0.52 0.52 l 177/195 177/195 177/195 RBetter Health

121a Provision of high quality care: hospitals 18-19 Q3 63.0 63.0 63.0 l 39/195 35/195 35/195 G Better Care

121bProvision of high quality care: primary medical services

18-19 Q3 64 66 66 l 166/195 99/195 99/195 G Better Care

121cProvision of high quality care: adult social care

18-19 Q3 62.0 62.0 62.0 l 77/195 99/195 99/195 G Better Care

128b Patient experience of GP services 2018 79.99% 80.0% 80.0% l 160/195 160/195 160/195 R Better Care

128cPrimary care access - percentage of registered population offered full extended access

2019 03 100% 100% 100% l 1/191 1/193 G Better Care

128d Primary care workforce 2018 09 0.91 0.90 0.90 l 127/195 158/195 158/195 R Better Care

128e

Count of the total investment in primary care transformation made by CCGs compared with the £3 per head commitment

18-19 Q4 Red Red Red l - - - R Better Care

186186

Commissioning – Planned

15



Target / Standard

Latest Period


CCG rating

Domain

122aCancers diagnosed at early stage

53.5% 2017 53.9% NULL 53.0% 71/195 - 77/195 R Better Care

122b

People with urgent GP referral having first definitive treatment for cancer within 62 days of referral

85% 18-19 Q4 78.9% 76.5% 75.6% 106/195 143/195 116/195 R Better Care

122cOne-year survival from all cancers

75.0% 2016 76.4% 77.0% 77.0% l 4/189 4/195 4/195 G Better Care

129aPatients waiting 18 weeks or less from referral to hospital treatment

92% 2019 03 80.0% 89.2% 89.2% 187/195 80/195 78/195 R Better Care

133a 6 week diagnostics (new) 1% 2019 03 2.1% 1.8% 1.5% 148/195 128/195 112/195 R Better Care

144a

Utilisation of the NHS e-referral service to enable choice at first routine elective referral

2019 03 92.1% 99.5% 99.9% 60/195 142/191 137/195 G Sustainability

187187

Commissioning - MH

16



Target / Std

Latest Period

Jan-19 Apr-19 Jul-19 Trend Jan-19 Apr-19 Jul-19Barnet CCG

ratingDomain

123aImproving Access to Psychological Therapies -recovery

50% 18-19 Q3 53.5% 52.4% 52.4% l 61/195 88/195 88/195 G Better Care

123bImproving Access to Psychological Therapies -access

4.20% 18-19 Q3 3.1% 3.6% 3.6% l 182/195 170/195 170/195 R Better Care

123cPeople with first episode of psychosis starting treatment within 2 weeks of referral

53% 2019 03 84.0% 81.6% 80.0% 61/195 78/195 89/195 A Better Care

123dChildren and young people’s mental health services transformation

- l - - Better Care

123eCrisis care and liaison mental health services transformation

2017-18 75% 75.0% l 25/180 25/180 G Better Care

123fMental Health Out of Area Placements (inpatient bed days per 100,000 population)

2019 02 612 282 336 193/195 168/195 175/195 R Better Care

123g Mental Health - health checks 18-19 Q4 23.9% - 120/195 G Better Care

123h Mental Health - cardio metabolic assessments - l - - Better Care

123i Mental Health - Investment standard 18-19 Q4 Compliant Compliant Compliant l - - G Better Care

123jMental Health - quality of data submitted to NHS Digital (DQMI)

2019 01 l - - Better Care

124aReliance on specialist inpatient care for people with a learning disability and/or autism

18-19 Q4 52 46 44 82/195 61/195 66/195 G Better Care

124bProportion of people with a learning disability on the GP register receiving an annual health check

2017-18 63.6% 63.6% 63.6% l 23/195 23/195 23/195 G Better Care

124cCompleteness of the GP learning disability register

2017-18 0.38% 0.38% 0.38% l 158/195 158/195 158/195 R Better Care

126aEstimated diagnosis rate for people with dementia

66.7% 2019 03 73.71% 73.3% 75.0% 47/195 48/195 42/195 G Better Care

126bDementia care planning and post-diagnostic support

2017-18 78.33% 78.3% 78.3% l 96/194 96/194 96/194 G Better Care188188

Commissioning - UEC

17



Target / Standard

Latest Period


CCG rating

Domain

104aInjuries from falls in people aged 65 and over (per 100,000 CCG registered population)

18-19 Q3 1,709 1,831 1,831 l 66/189 61/195 61/195 GBetter Health

105cPercentage of deaths with three or more emergency admissions in last three months of life

2017 0 5.6% 7.4% 104/194 103/194 86/195 ABetter Health

106aInequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions

18-19 Q2 1,501 1,508 1,508 l 26/195 26/195 26/195 GBetter Health

127bEmergency admissions for urgent care sensitive conditions (per 100,000 registered population)

18-19 Q2 1,586 1,657 1,657 l 12/195 12/195 12/195 GBetter Care

127cPercentage of patients admitted, transferred or discharged from A&E within 4 hours

95% 2019 03 84.8% 86.7% 86.7% l 107/195 78/195 78/195 RBetter Care

127eDelayed transfers of care per 100,000 population

2019 03 7.5 9.9 9.5 62/195 98/195 102/195 ABetter Care

127fPopulation use of hospital beds following emergency admission (per 1,000 population)

18-19 Q2 426.8 425.1 425.1 l 31/195 28/195 28/195 GBetter Care

189189

Commissioning - Other

18



Target / Standard

Latest Measurement Period


CCG rating

Domain

102aPercentage of children aged 10-11 classified as overweight or obese

2015-16 to 2017-18

33.06%

33.1% 33.2% 112/195 112/195 113/195 ABetter Health

103bPeople with diabetes diagnosed less than a year who attend a structured education course

2017-18 (2016 cohort)

2.6% 2.6% 2.6% l 156/195 156/195 156/195 RBetter Health

125c Choices in maternity services 201865

63.4 63.4 l 31/195 51/195 51/195 GBetter Care

125d Maternal smoking at delivery 6% 18-19 Q3 3.94% 2.76% 2.76% l 13/195 7/195 7/195 GBetter Care

190190

Quality

19



Target / Standard

Latest Period


CCG rating

Domain

105bPersonal health budgets (per 100,000 CCG responsible population)

18-19 Q4 20.3 21.7 52.5 82/195 102/195 64/195 GBetter Health

121aProvision of high quality care: hospitals

18-19 Q3 63.0 63.0 63.0 l 39/195 35/195 35/195 GBetter Care

121cProvision of high quality care: adult social care

18-19 Q3 62.0 62.0 62.0 l 77/195 99/195 99/195 GBetter Care

122d Cancer patient experience 2017 8.5 8.5 8.5 l 182/195 182/195 182/195 RBetter Care

125a Neonatal mortality and stillbirth 2016 4.9 4.9 4.9 l 115/195 80/194 80/194 GBetter Care

125bWomen’s experience of maternity services

2018 80.1 81.3 81.3 l 160/195 127/195 127/195 GBetter Care

130aAchievement of clinical standards in the delivery of 7 day services

2017-18 2.0 2.0 2.0 l 56/195 56/195 56/195 GBetter Care

131aPercentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting

15% 18-19 Q4 4% 8% 12% 77/195 109/195 153/195 RBetter Care

132a

Evidence that sepsis awareness raising amongst healthcare professionals has been prioritised by the CCG

2018 Amber Amber Green - - GBetter Care

191191

Corporate

20



Target / Standard

Latest Period


CCG rating

Domain

141b In-year financial performance 18-19 Q4 Red Red Red l - - R Sustainability

145aExpenditure in areas with identified scope for improvement

18-19 Q3 N/A N/A N/A l - - - Leadership

162a Probity and corporate governance 18-19 Q4Fully

compliantFully

compliantFully

compliantl - - G Leadership

163a Staff engagement index 2018 3.815 3.815 3.817 42/189 42/189 51/189 G Leadership

163bProgress against Workforce Race Equality Standard

2018 0.2 0.2 0.2 171/189 165/189 173/189 R Leadership

164aEffectiveness of working relationships in the local system

2018-19 61.9 61.9 69.6 144/189 144/189 92/195 G Leadership

165a Quality of CCG leadership 18-19 Q4 Green Green Amber - - A Leadership

166a

Assessing CCG compliance with statutory guidance standards of public and patient participation in commissioning health care

- Amber Amber Amber l - - A Leadership

192192


Report Title M4 Finance Report

Agenda Item 4.4


Simon Goodwin, CFO, NCL CCGs



Matt Backler, Director of Finance, Barnet CCG


Report Author

Bev Tipping, Head of Finance, Barnet CCG


Report Summary

At month 4 (M4) the CCG is forecasting to deliver its planned £6.7m deficit. This remains stretching but not unfeasible. However there are a number of risks to the plan and given that the CCG does not hold a contingency there are no mitigations should these arise. The year-to-date position is a £3.2m deficit (£0.2m adverse to plan). Delivery of the Quality, Innovation, Productivity and Prevention (QIPP) Programme is forecasting delivery £17.9m (98%) of its £18.2m target. The overall risk value above the Forecast Outturn is at £5.0m. The most significant risks relate to acute (Royal Free performance up to contract cap). Best and worst case analysis has identified a range of circa £4.2m deficit £11.8m.

Recommendation The Governing Body is to NOTE the M4 (2019-20) Finance position


The financial risks are set out in the report and are managed through general principles of financial control (reporting, challenge, recovery plans etc). Financial risk is included in the Governing Body Assurance Framework


Not Applicable


Resourcing implications shown in the ‘investment’ column and agreed with finance team. These have been be approved as part of the 2019/20 QIPP Planning Process.

Engagement

The finance report is built up through engagement with budget holders in determining the financial position


Not Applicable


The detailed finance report is presented each month to the Finance, Performance and QIPP committee

A summary finance report is presented at each Governing Body

193193

Next Steps Continue to monitor the financial position

Appendices

None

194194

Finance Report 2019-20Month 4 (July 2019)

Lead Director: Matt BacklerAuthor: Beverley Tipping

195195

Finance Report M4

At Month 4 North Central London (NCL) CCGs are forecasting to deliver the £41.0m planned deficit. There is £2.0m of forecast QIPP slippage and £26.4m of risk.

1

• At month 4 (M4) there is an adverse Year to Date (YTD) variance of £1.1m.• M4 forecast outturn (FOT) across NCL commissioners is in line with the planned £41.0m deficit (same as prior

month).• There is an overall Net risk of (£26.4m) to the achievement of NCL CCG financial plans (which has increased from

£22.6m in the prior month)• The Quality, Innovation, Productivity and Prevention (QIPP) Programme has a YTD variance of £2.8m and a full year

variance of £2.0m.

NCL M4 summary Financial Position

Source: Non-IFSE return M4

Annual Plan YTD Var. FOT Var. YTD Var. FOT Var.

19/20 Plan FOT

Barnet (6.8) (0.2) - (0.3) (0.3) (5.4) (6.8) (6.8)Camden (4.8) (0.3) - 0.0 (0.6) (3.5) (4.8) (4.8)Enfield (15.4) - - (2.4) - (8.2) (15.4) (15.4)Haringey (14.1) (0.2) - (0.1) (0.5) (5.5) (14.1) (15.5)Islington - (0.4) - (0.2) (0.7) (3.7) - 2.6Total (41.0) (1.1) - (2.8) (2.0) (26.4) (41.0) (39.8)Prior month (41.0) (0.1) 0.0 (0.3) (0.0) (22.6) (41.0) (45.3)

Bottom line QIPP Underlying position

Net risks

196196

Finance Report M4

At M4 the CCG is forecasting to deliver its planned £6.7m deficit. This remains challenging but not unfeasible. There remain a number of risks to delivery.

2

Executive Summary

Summary

• Forecast: At M4 the CCG is forecasting to deliver its planned £6.7m deficit. There continue to be risks to delivery, the most significant being in relation to acute over-performance.

• Year to date: £3.2m deficit compared to a £3.0m deficit.

• Acute is forecast to overspend by £0.6m. This is driven by overspends in both in sector and out of sector acute, offset by underspends in non-contract activity. Further work is being undertaken to understand these variances and challenge where appropriate.

• Non acute: Non-Acute is forecasting a £0.5m overspend driven by overspends in mental health and learning disability high cost placements.

• Corporate: Running costs are forecasting to be £0.4m below plan due to a number of staffing vacancies in the first few months of the year.

• QIPP: The CCG is forecasting to achieve £17.9m (98%) of the QIPP target of £18.2m. YTD QIPP delivered is £4.6m compared to a planned £4.9m.

Summary financial position (£m)

Bud Actual Var Bud FOT VarRevenue Resource Limit 196.0 196.0 - 588.3 588.3 -

Acute 103.9 103.9 (0.0) 308.7 309.2 0.6Non-Acute 88.9 89.7 0.8 267.8 268.3 0.5Corporate & running costs 6.1 5.9 (0.1) 18.5 17.9 (0.7)Total Operational 198.9 199.6 0.6 595.0 595.4 0.4Total Non Operational - (0.4) (0.4) - (0.4) (0.4)Total Expenditure 198.9 199.2 0.2 595.0 595.0 0.0Surplus / (Deficit) (3.0) (3.2) (0.2) (6.7) (6.7) (0.0)

YTD Full Year

Acute performance (£m)

Bud Actual Var Bud FOT Var£m £m £m £m £m £m

Royal Free 67.9 68.2 0.3 201.5 201.5 0.0UCLH 9.4 9.5 0.1 27.9 28.2 0.2Other acute 26.6 26.2 (0.4) 79.3 79.6 0.3Total Acute 103.9 103.9 (0.0) 308.7 309.2 0.6

Prior month 77.6 78.0 0.4 310.5 310.5 (0.0)

Trust / ServiceYTD Full Year

197197

Finance Report M4

At M4 the net reported risk for the CCG is £5.0m, which is in line with the operating plan submission.

3

Risk & Mitigations

• There are no material changes to the risks since month 3. The most significant risks relate to acute performance and Royal Free performance being above the baseline.

• The Royal Free contact has a cap and collar which limits the risk of over and underperformance to +/- £2.5m, the risk of reaching this level of performance has been included above. This includes the risk of under delivery of QIPP at the Royal Free.

• QIPP risk is shown as nil as risks are offset by mitigations of further stretching and delivery of QIPP. In addition the majority of the QIPP risk is on schemes impacting Royal Free, the risk relating to this is included in the Royal Free contract risk line as set out above.

• Worst case scenario shows a potential deficit of £11.8m if all the risks materialise. The best case scenario includes an assumption that the Royal Free contract performs below the baseline and none of the other risks materialise.

RisksPrevious

Month Risk £'000

Operating Plan Risk

Emergent Risk at M4

£'000

Emergent Risk at M2 Description

FOT (6,747) (6,747)Acute over-performance (902) Med (902) Med Out of sector acutes perform above budgeted growth assumptions. This has been a problem

historically however significant levels of growth in line with historical trends have been budgeted to mitigate this

Royal Free Contract up to Cap (2,500) High (2,500) High Royal Free performance is above the baseline. This could be up to £2.5m and there is no contingency to mitigate this.

CHC (839) Med (839) Med Continuing Healthcare is an on-going risk, however the risk is lower than in previous years due to detailed budgeting and additional controls put into place in the second half of 2018/19.

GP at Hand (314) Low (478) High Costs relating to GP at Hand QIPP risk - Low - LowPrescribing (293) Low (293) Med NCSO CostsTotal - risk (4,848) (5,012)Worst case (11,595) (11,759)

Mitigations / UpsideFOT (6,747)Royal Free Contract 2,500 Royal Free performance is below the baselineBest Case (4,247)

198198

Barnet Clinical Commissioning Group

Governing Body Meeting

19 September 2019

Report Title Governing Body Board Assurance Framework and Risk Appetite Update

Agenda Item 4.5


Kay Matthews, Chief Operating Officer, Barnet CCG


GB Member Sponsor

Helen Pettersen, Accountable Officer

Report Author

Chris Hanson, Governance and Risk Lead NCL CCGs



Not Applicable

Summary of Financial Implications The GBAF report assists the CCG in managing its most significant financial risks.

Report Summary

This report is the Governing Body Board Assurance Framework (‘GBAF’). It captures the most serious risks that have been identified as threatening the achievement of Barnet CCG’s five strategic objectives. Key risks from the North Central London Primary Care Co-Commissioning Committee in Common (‘NCL PCC’) risk register, NCL Joint Commissioning Committee (‘NCL JCC’) risk register and NCL Risk Register are reported to the Governing Body to ensure visibility and oversight. Risks from the NCL JCC risk register and the NCL risk register are from an NCL perspective. However, risks from the NCL PCC risk register can be from either a local perspective or a pan NCL perspective depending on the risk. Board Assurance Framework (‘GBAF’) There are 4 risks that reach the threshold of 15 or higher for inclusion on the GBAF. The full version of the GBAF can be found here. Key Highlights: CRR1: Failure to Deliver 2019/20 Statutory and Other Financial Requirements Set By NHS England (Threat). The CCG has set a stretching but not unfeasible budget for 19/20. However this contains significant risk and there is no contingency built into the plan. Presently we consider adequate controls in place but this will be carefully monitored throughout the year. Risks reporting is in line with that submitted in the Operating Plan submission with the addition of GP at Hand risk. At M4 the year to date position is £3.2m deficit (compared to plan of £3.0m). The CCG is still forecasting to deliver its planned £6.7m deficit, but there remains a number of risks to delivery. There is significant

199199

http://www.barnetccg.nhs.uk/privacy.htm



http://www.barnetccg.nhs.uk/downloads/boardpapers/2019/0919/Hyperlink-1-Barnet-GBAF-12-August-2019.pdf

over performance showing at the Whittington and this is being investigated urgently, this over performance has been factored into the forecast. This risk relates to CRR2. This risk is rated 16. CRR2: Failure to Deliver the 2019/20 QIPP and Transformation Programme (Threat). The Royal Free London (‘RFL’) Acute Contract has been agreed and signed. The 2019/20 QIPP Position at M03 reported a net Forecast Outturn of £18.2m, which is an immaterial adverse variance of £9k to plan. The main focus is the 2019/20 STP Acute Review Tool data verification for reporting. The CCG is working closely with NELCSU to set up a robust monitoring process for all NCL CCGs. To reduce risks in-year, monthly NCL QIPP Position meetings are held to review monitoring data and to ensure consistency in reporting across NCL. These review meetings are also supported by the Local Delivery Group – where RFL Operational and Transformational leads are in attendance - and locally at the QIPP Delivery Group (QDG) meeting where progress is scrutinised against the key milestones and plans. This risk is rated 15. NCL Risk Register There are 14 risks on the NCL Risk Register with 1 risk having a current risk score of 15 or higher. Three change programme risks and a Brexit risk have been identified and have been added to the NCL risk register. These include risk on:

Destabilisation as a result of the UK leaving the European Union; Failure to deliver an Integrated Care System; Failure to deliver the mandated twenty percent management cost

reductions; Failure to merge the five CCGs.

The full version of the NCL Risk Register can be found here. Key Highlights: NCL9: Delivering Financial Balance across the NCL CCGs. At 18/19 outturn (subject to audit) NCL CCGs reported a combined deficit of £50.7m. There were deficits at Barnet £9.6m, Enfield £24.8m, Haringey £17.9m offset by surpluses of Islington £1.5m and Camden £0.1m. For 19/20 CCGs have submitted a combined deficit of £41m with a net additional risk of £22m. It will be challenging to manage this net risk during 19/20. NCL CCGs will be developing a Medium Term financial strategy in the Spring/Summer as part of the STP requirement for the NHS Long term plan. The Medium Term financial strategy will include a plan to bring the NCL STP health economy into balance over the next 2/3 years. At Month 4 all CCGs remain on Plan, though risks (particularly in primary care with GP@Hand) are growing. This risk is rated 20. NCL11: Destabilisation as a result of the UK’s planned exit from the European Union. NHSE preparatory work was suspended in the Spring following the Government’s announcement of the revised timescales for the United Kingdom to exit the European Union. At the point of suspension all NCL CCGs were fully compliant with requirements. Further preparatory steps are expected in September 2019 and, in liaison with NHS England, the NCL CCGs will continue to manage and support readiness arrangements. The risk to the wider health care system is greater than to the NCL CCGs’ operation. The NCL CCGs will support the wider system, including Trusts and Primary Care, in liaison with NHSE. This risk is rated 9.

200200

http://www.barnetccg.nhs.uk/downloads/boardpapers/2019/0919/Hyperlink-2%20-NCL-register-3-September-2019.pdf

NCL12: Failure to deliver an Integrated Care System (ICS) across the North Central London (NCL) CCGs. NCL has established an NCL-wide task and finish group on Integrated Care System design, working alongside developing local integrated care partnerships at borough level. An engagement advisory board is in place to help shape engagement with residents across NCL on these developments. This risk is rated 8. NCL13: Failure to deliver NHS England 20% management costs reduction. A detailed review has now taken place to fully understand the financial savings required to deliver the 20% reduction in time for 2020/21. The required reductions in management costs would be deliverable through the proposed NCL CCGs’ merger from April 2020. In the event of the merger not proceeding to this timescale a revised reduction plan will be required. This risk is rated 9. NCL14: Effective Delivery of Corporate Merger. Significant work has gone into the development of plans to deliver a merger of the five North Central London CCGs, and these continue to progress at pace. There remains significant risk that key issues that impact on the ability of CCG members, stakeholders, and partners to support the formal corporate merger of the CCGs will not be resolved in time to allow this to happen as planned on 1st April 2020. The work to move to a single CCG structure and to support ICS and ICP development will continue regardless of the date of the merger. This risk is monitored on a very regular basis by NCL SMT and the NCL Assurance and Oversight Group. This risk is rated 12. NCL Primary Care Commissioning Committee in Common Risk Register There are 7 risks on the NCL Primary Care Co-Commissioning Committee in Common (‘NCL PCCC’) Risk Register with 1 risk having a current risk score of 15 or higher. Risk PCCC 24 (The Establishment of Primary Care Networks, as set out in the new national GP contract needs to align with local primary care strategies and primary care provision including GP Federations, and avoid potential conflicts of interest) is included in this report to highlight the risk to the Governing Body. The NCL PCCC Risk Register can be found here. Key Highlights: PCCC18: Inadequate support from Primary Care Support England (Capita contract) for general practices. Capita have recommenced the patient list cleansing process in agreement with NHS England. The London process will start in North Central London. The timeline for the list cleansing process, requested by the Committee in April 2019, is set out below: Current - people aged over 100 on practice lists; From June 2019 – People under 16 and demolished properties; From September 2019 - homes with high multiple occupancy, students (this may be moved forwards), and transient population. This risk is rated 16. PCCC24: The Establishment of Primary Care Networks, as set out in the new national GP contract needs to align with local primary care strategies and primary care provision including GP Federations, and avoid potential conflicts of interest. The following work has been undertaken to manage the establishment of primary care networks (PCNs): • Establishment of PCNs in NCL in line with national guidance including geographic coherence and population size, and through a bottom-up process with practices and the Local Medical Committee; • Approval of PCN proposals across NCL by the Committee in June 2019;

201201

http://www.barnetccg.nhs.uk/downloads/boardpapers/2019/0919/Hyperlink-3-NCL-format-PCCC-risk-register-June-2019.pdf

• Organisation development programme being developed for Clinical Directors of the PCNs; • Establishing primary care provider meetings to align the work of GP Federations and PCNs; • Amendment of declarations of interest to include PCN membership for general practice members of CCG Governing Bodies and Committees. This risk is rated 9. NCL Joint Commissioning Committee Risk Register There are 7 risks on the NCL Joint Commissioning Committee (NCL JCC’) Risk Register with 2 risks having a current risk score of 15 or higher. The NCL JCC Risk Register is being further developed and strengthened so the detailed register is not included and instead the strategic highlight report can be found here. Key Highlights: JCC13: Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat). In addition to After action reviews for winter 2018/19 relating to delivery of the four hour A & E waiting time standard: • Surge hub support, provided by Northeast London Commissioning Support Unit (NELSCU), has been extended from 5 days to 7 days for the winter period. The surge hub support delivery of escalation actions as urgent and emergency care system pressure increases; • Operating plan profiles elective activity to minimise routine work at times of peak demand for emergency pathways. Capacity for emergency surgery and cancer maintained over the winter period; • Plans to reduce extended lengths of stay (over 21 days) by 40% by March 2019 compared to March 2018 with weekly discharge profiles submitted to encourage reducing this patient cohort; • Plans to eliminate ambulance handovers waits into emergency departments in excess of 30 minutes from October 2019; • Plans to increase GP streaming in emergency departments. This risk is rated 16. JCC28: Supporting system financial recovery through contracts (Threat). Mitigations underway include: • Workshops to develop medium-term financial strategy for NCL held on 3 May and 19 July 2019, focusing on both recovery actions for 2019/20 and developing actions for the medium-term to bring NCL as a system into financial balance; • NCL-wide and Borough-based “Intergreat” events held with NCL STP stakeholders to simulate the introduction of local integrated care systems. The outcome will inform planning for 2019/20; • Establishment of Local Delivery Groups with providers to support delivery of QIPP and provider cost improvement programmes; • Financial plans for 2020/21 are being developed in preparation for submission of the NCL response to the NHS Long Term Plan. First cut plans will go to the STP Directors of Finance meeting on 26 July 2019 for consideration; • Cap and collar constructs have been agreed for the contracts with Royal Free London and North Middlesex University Hospital for 2019/20, and a block contract for UCLH in 2019/20 and 2020/21. This risk is rated 20. Risk Appetite Scores On 11th July 2019 the Governing Body met to discuss and agree its risk appetite scores in accordance with the CCG’s risk management strategy and policy. The risk appetite scores set the high level principles underpinning the CCG’s approach

202202

http://www.barnetccg.nhs.uk/downloads/boardpapers/2019/0919/Hyperlink-4-JCC-Risk-Tracker-August-2019-V2-24-July-2019.pdf

to each area of risk and risk culture. The new risk appetite scores are found at appendix 2 of this report

Recommendation The Governing Body is asked to review the GBAF highlight report and provide feedback on the risks.


The GBAF is a risk management document which highlights the most significant risks to the achievement of the CCG’s strategic objectives.


Conflicts of interest are managed robustly and in accordance with the CCG’s conflict of interest policy.


Updating of the GBAF is the responsibility of each risk owner and their respective directorates. The Governance Team helps to support this by providing monitoring, guidance and advice.

Engagement

The GBAF report is presented to each Governing Body meeting. The Governing Body includes clinicians, lay members and representatives of patients and other key stakeholders.


This report was written in accordance with the provisions of the Equality Act 2010.


The GBAF was last reviewed by the Governing Body on 20 June 2019. Risks are kept under review by the risk owners and by the committees of the Governing Body.

Next Steps To continue to manage risk across the organisation in a robust way.

Appendices

The following documents are included: BAF Risks Highlight Report; Risk Scoring Key. Risk Appetite Scores

203203

204204

Risk ID Risk Title Risk Owner Strategic Update JAN MAR JUNE SEPTGBAF 20 Failure of Royal Free

London Hospital to Meet NHS Constitutional Standards Trajectory e.g. A&E, RTT and 62 Day Waits in 2019/20 (Threat)

Ali Malik Director of QIPP, Planning and Performance

This risk has been redefined to refer to the financial year 2019/20 only, however, as an ongoing risk the historical data has been retained to demonstrate performance over time. Performance against cancer targets is variable, however improvements in clinical pathways are being made (particularly lower Gastrointestinal). There is significant risk of recovery against the Referral To Treatment (‘RTT’) standard in the shorter term given suspension of national reporting and operational issues. A&E performance is challenged due to operational capacity. To address these issues Barnet CCG continues to work closely with Royal Free London and is leading on joining up performance management across the system by inviting key stakeholders such as NHS England and NHS Improvement to the Barnet CCG led Performance Review Group meetings. Recovery actions are being linked to wider system transformation plans to ensure sustainable position going forward. The risk remains high despite mitigating actions taken by the CCG.

16 16 16 16 12

GBAF 21 Failure to ensure that quality and patient safety are maintained at the Royal Free London (Threat)

Jenny Goodridge, Director of Quality and Clinical Services

This risk remains high as the actions from the Remedial Action Plan (RAP) have not yet been fully implemented. All incidents have now been investigated and action plans put in place to address the root causes. Barnet CCG are in the process of testing the evidence for the action plans. In the meantime, it remains difficult to be assured that the root causes have been addressed, and it is too early to tell if the plan has had a significant impact. 20 20 20 20 8

CRR1 Failure to Deliver 2019/20 Statutory and Other Financial Requirements Set By NHS England (Threat)

Matt Backler- Director of Finance

The CCG has set a stretching but not unfeasible budget for 19/20. However this contains significant risk and there is no contingency built into the plan. Presently we consider adequate controls in place but this will be carefully monitored throughout the year.

Risks reporting is in line with that submitted in the Operating Plan submission with the addition of GP at Hand risk. At M4 the year to date position is £3.2m deficit (compared to plan of £3.0m). The CCG is still forecasting to deliver its planned £6.7m deficit, but there remains a number of risks to delivery. There is significant over performance showing at the Whittington and this is being investigated urgently, this over performance has been factored into the forecast.

15 16

12

BAF Risks- Highlight Report 2019/20Movement From

Last ReportTarget Risk

ScoreCurrent Risk Score

205205

CRR2 Failure to Deliver the 2019/20 QIPP and Transformation Programme (Threat)

Ali Malik Director of QIPP, Planning and Performance

The RFL Acute Contract has been agreed and signed.

The 2019/20 QIPP Position at M03 reported a net FOT of £18.2m, which is an immaterial adverse variance of £9k to plan.

The main focus is the 2019/20 STP Acute Review Tool data verification for reporting. The CCG is working closely with NELCSU to set up a robust monitoring process for all NCL CCGs.

To reduce risks in-year, monthly NCL QIPP Position meetings are held to review monitoring data and to ensure consistency in reporting across NCL. These review meetings are also supported by the Local Delivery Group – where RFL Operational and Transformational leads are in attendance - and locally at the QIPP Delivery Group (QDG) meeting where progress is scrutinised against the key milestones and plans.

15 15 9

Risk Key

Risk Improving

Risk Worsening

Risk neither improving nor worsening but working towards target

206206

Risk Scoring Key This document sets out the key scoring methodology for risks and risk management.

1. Overall Strength of Controls in Place There are four levels of effectiveness: Level Criteria Zero The controls have no effect on controlling the risk. Weak The controls have a 1- 60% chance of successfully controlling the risk. Average The controls have a 61 – 79% chance of successfully controlling the risk Strong The controls have a 80%+ chance or higher of successfully controlling the risk

2. Risk Scoring

This is separated into Consequence and Likelihood. Consequence Scale: Level of Impact on the Objective

Descriptor of Level of Impact on the Objective

Consequence for the Objective

Consequence Score

0 - 5% Very low impact Very Low 1 6 - 25% Low impact Low 2 26-50% Moderate impact Medium 3 51 – 75% High impact High 4 76%+ Very high impact Very High 5

Likelihood Scale: Level of Likelihood the Risk will Occur

Descriptor of Level of Likelihood the Risk will Occur

Likelihood the Risk will Occur

Likelihood Score

0 - 5% Highly unlikely to occur

Very Low 1

6 - 25% Unlikely to occur Low 2 26-50% Fairly likely to occur Medium 3 51 – 75% More likely to occur

than not High 4

76%+ Almost certainly will occur

Very High 5

207207

208208

3. Level of Risk and Priority Chart

This chart shows the level of risk a risk represents and sets out the priority which should be given to each risk:

LIKELIHOOD

CONSEQUENCE

Very Low (1)

Low (2)

Medium (3)

High (4)

Very High (5)

Very Low (1)

1 2 3 4 5

Low (2)

2 4 6 8 10

Medium (3)

3 6 9 12 15

High (4)

4 8 12 16 20

Very High (5)

5 10 15 20 25

1-3

Low Priority

4-6

Moderate Priority

8-12

High Priority

15-25

Very High Priority

209209

210210

Schedule 2 Risk Appetite

This schedule sets out the CCG’s risk appetite as agreed by the Governing Body on 11th July 2019. The chart below shows the appetite grading for risks based on their potential impact Appetite Description Appetite

Level

The CCG is not willing to accept these risks under any circumstances 1

The CCG is not willing to accept these risks (except in very exceptional circumstances)

2

The CCG is willing to accept some risk in this area 3

The CCG is willing to accept moderate risk in this area 4

The CCG is willing to accept high risk in this area 5

The chart below shows the CCG’s risk appetite in each area:

No. Service Area Governing Body Statement Appetite Level

1. Quality We will ensure equitable, high quality services for all the people of the borough and will only rarely accept risks which threaten that goal.

2

2. Safety We hold patient and staff safety as the highest priority and will not accept any risk that threatens either.

1

3. Compliance with legislation

We will comply with all legislation relevant to the CCG and we will only accept risks that do not breach fundamental duties.

2

4. Conflicts of Interest

We will preserve the integrity of our decision making processes and our decisions and will comply with statutory guidance. Given the nature of CCGs and the challenges of delivering national and local plans such as the Five Year Forward view we are willing to accept some risks in certain circumstances but these will be managed robustly.

2

211211

5. Reputation We intend to maintain high standards of conduct and will accept risks that may cause reputational damage only in certain circumstances, and only when the benefits merit the risk.

3

6. Innovation & Productivity

We aim to foster, and will encourage, a culture of innovation and efficiency; in so doing we are prepared to accept the concomitant risks. However, when doing so we will work within the risk appetite levels for each Service Area set out in this document and will not exceed them.

4

7. Finance We will stay within set financial limits and will not accept any risks which, if realised, would cause a breach but the achievement of strategic objectives, value for money and cost effectiveness can justify calculated risk.

3

8. Partnerships We will work with other organisations to ensure the best outcome for patients and are willing to accept the risks associated with a collaborative approach.

4

Precedence of Risk Appetite Scores For the avoidance of doubt where two risk appetite scores conflict with each other the lowest risk appetite score takes precedence. For example, the CCG may be working on a new and innovative service and so work within the risk appetite level of 4 for Innovation and Productivity. However, whilst doing so the CCG will work within the risk appetite levels of 1 for Safety and 2 for Quality.

212212


Report Title Summary of Meetings of the Committees of Barnet CCG Governing Body

Agenda Items 5.1 – 5.4


Matt Backler (Clinical Commissioning, Finance and QIPP Committee)


Colette Wood (Primary Care Procurement Committee)


Jenny Goodridge and Ali Malik, (Quality and Performance Committee)


Vee Scott (Public and Patient Committee)


Report Author

Andrew Simpson, Board Secretary, Barnet CCG


Report Summary

This paper presents a summary of the business conducted at the following Committees of the Barnet CCG Governing Body:

Item 4.1: Quality and Performance Committee (Chair – Dr Barry Subel) Item 4.2: Clinical Commissioning, Finance and QIPP Committee (Chair

– Dr Barry Subel) Item 4.3: Primary Care Procurement Committee (Chair – Ian Bretman) Item 4.4: Public and Patient Engagement Committee (Chair – Ian

Bretman)

Recommendation The Governing Body is asked to NOTE the report.


Not Applicable


Not Applicable


Not Applicable

Engagement

Not Applicable


Not Applicable


Not Applicable

213213



Next Steps Not Applicable

214214

Quality and Performance Committee Meeting (5.1)

Summary of the meeting held on 1 August 2019

At its meeting on 1 August 2019, the Governing Body’s Quality and Performance Committee undertook the following activity:

Received a presentation on the Suicide Prevention strategy, which provided an overview of work being undertaken to support the Barnet Suicide Prevention Action Plan 2019/20 which is led by Public Health Barnet;

Discussed the current North Central London (NCL) CCG Change Programme which aims to deliver improved outcomes for North Central London (NCL) residents through the proposed formation of an Integrated Care System;

Received a presentation on Healthwatch Themes and Trends, which provided an update on their key projects, intelligence on service providers and recommendations;

Received a presentation on the Equality and Diversity Annual Report demonstrating how Barnet CCG takes forward activities to meet the Public Sector Equality Duty by implementing NHS mandatory standards. Highlights of the most recent staff survey results were shared, noting improvements from the 2017 staff survey results;

Noted the annual report on maternity service performance and quality outcomes for Royal Free Hospital and Barnet Hospital;

Heard a verbal update on Continuing Healthcare covering the Joint Funded packages (s117) scheme.

The Committee reviewed an integrated quality and performance report which provided information on provider performance in relation to a number of key quality metrics and constitutional access standards, such as RTT. Risk registers detailing the risks to the achievement of these standards were also reviewed.

The Committee also noted the minutes of the Clinical Quality Review Groups of the following providers in order to gain assurance on quality:

Royal Free London Central London Community Healthcare Barnet, Enfield and Haringey Mental Health Trust Royal National Orthopaedic Hospital.

215215

Clinical Commissioning, Finance and QIPP Committee Meetings (5.2)

Summary of the Meetings Held on 30 May, 27 June and 25 July 2019

At each meeting of the Barnet CCG Governing Body’s Clinical Commissioning, Finance and QIPP Committee (CFQ), clinical and lay members of the Committee:

Provide oversight of the CCG’s financial position and performance in delivery of its QIPP programme;

Receive updates on information management technology developments and business conducted by the CCG’s Programme Oversight and Development Group (PODG);

Review risks from the CCG’s corporate risk register which have a risk rating of 12 or greater and sit within the Committee’s remit;

Review and approve any non-primary care commissioning and investment proposals; Review any other reports which have been produced in response to members’ requests

for assurance on any relevant matter.

At the meetings held in May, June and July, committee members discussed the CCG’s financial position for the first quarter of 2019-20 (stated in the context of the overall position for North Central London CCGs), noting that the CCG was forecasting to deliver its financial plan of a £6.7m deficit. Delivering the plan was considered challenging but achievable. Members noted that risks to delivering the plan remained consistent in nature with those described in the CCG’s operating plan: Continuing Healthcare overspend, acute over-performance and ‘no cheaper stock option’ prescription costs (this being the most significant). The CCG was forecasting to achieve its full QIPP target of £18.2m throughout quarter one. Members sought assurance on the deliverability of the schemes in light of there being no available contingency funding, and achievement of the financial plan therefore being reliant upon full delivery of the QIPP target. Risks to the delivery of financial and QIPP targets are captured on the Committee’s Risk Register, which was given detailed scrutiny at each of the three meetings during quarter one. In line with its remit to provide oversight of the implementation of the CCG’s digital strategy, members received updates on progress of local system-wide digital transformation. As well as progress in the implementation of the Health Information Exchange, for which Barnet was a pilot site, focus was given to the steps taken by the CCG to implement the NHS Long Term Plan’s vision in relation to digital technology, including applications to encourage patient self-care and facilitate proactive population health management. The following is a summary of formal business undertaken at each of the meetings: May The Committee:

Approved the CCG’s procurement recommendations for children’s audiology services; and

Reviewed the CCG’s final 2019-20 budget document which had been submitted to NHS England (NHSE) on 15 May 2019.

June The Committee received an update on capital charges accrued to North Central London CCGs resulting from digital investment, following the Committee’s approval of the principle of sharing capital charges with providers equally in March 2019.

216216

July The Committee received an update on ophthalmology services procurement and mobilisation.

217217

Summary Report of Primary Care Procurement Committee Meeting (5.3)

Summary of the Meeting Held on 11 July In July the Primary Care Procurement Committee (PCPC) approved the CCG’s approach to the implementation in Barnet of NHSE’s recommendation to cease the issuing of GP prescriptions for medicines which could be purchased over the counter from a pharmacy or other outlets. In discussion of the proposals, members sought and received assurance that:

The impact upon residents who would not usually be required to pay for prescriptions, and might not be able to afford to buy some medication over the counter, would be monitored in order to avoid unintended health inequalities; and

GPs would retain discretion to issue prescriptions wherever a clinical need was identified.

The Committee provided oversight of the processes in place to monitor the effectiveness of locally commissioned services (LCS); how they are administered financially; and the extent to which they are achieving their objectives. Particular focus was given to the LCS scheme for improved GP access, for which 48 out of Barnet’s 52 practices had progressed through both stages of the two-part funding application process. The process involved the development by each practice of a high-priority area action plan designed to improve access. An example was given of success at a particular practice, which had improved appointment availability and reduced the number of patients who did not attend appointments, through the introduction of a new system and set of processes to manage appointments more effectively. Summary of the meeting held on 14 August In August the PCPC agreed unanimously to make recommendations to the NCL Primary Care Co-Commissioning Committee in Common (NCL PCCC) to approve the relocation of Ravenscroft Medical Centre to Finchley Memorial Hospital, and to approve the associated revenues and next steps. Throughout the process, including at the meeting on 14 August, members had had the opportunity to seek and receive rigorous assurance in relation to the application, decision-making and consultation processes. Approval of the relocation of Ravenscroft Medical Centre was given subsequently at the meeting of the NCL PCCC on 22 August. Also at its meeting on 14 August, the PCPC received an update on the engagement process to support consideration of the future of Cricklewood Walk-in Centre, noting in particular a change in timeframe of the engagement exercise to run between 12 August and 2 November 2019. The Committee was assured on the process to formalise plans, which included close collaborative working with Brent CCG, whose patients make up a majority of those who use the walk-in services at the centre.

218218

Summary Report of Patient and Public Engagement Committee Meeting (5.4) Summary of the Meeting held on 13 June 2019

In preparation for a period of engagement on the future of Cricklewood walk-in service, the Committee received an overview of the direction of travel for urgent and emergency care in Barnet. The purpose was to collected feedback on the CCG’s approach and to seek agreement on effective ways to communicate and engage when asking residents’ views on the walk-in service. The Committee will continue to review and provide scrutiny of the approach taken.

There was discussion of the latest developments in relation to the formation of the new Primary Care Networks (PCNs) in Barnet, for which members will support the development of a communications and engagement approach for the networks. Members felt that PCNs would be an important delivery channel for the NHS Long-Term Plan.

Healthwatch Barnet presented the findings of a survey carried out at emergency departments at the Royal Free London and Barnet Hospitals. Results indicated that two thirds of patients could have been seen elsewhere and that clear and consistent communications on alternative services was needed.

Public Health Barnet reported on a diabetes awareness event held at Brent Cross Shopping, which received excellent support from GPs, the Federation and various community partners. The event featured on the One Show (BBC).

219219

220220

Item 3:

Page 1 of 6

NORTH CENTRAL LONDON PRIMARY CARE COMMITTEE IN COMMON (Meeting held in public)

Minutes of the Meeting held on Thursday 18 April between 3pm and 4:30pm

Hendon Town Hall, Committee Room 1, The Burroughs, London NW4 4AX Present: Voting Members: Ms Cathy Herman (Chair) Governing Body Lay Member, Haringey CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG (Deputising for Karen

Trew, Enfield CCG) Mr Ian Bretman Governing Body Lay Member, Barnet CCG Ms Kathy Elliot Governing Body Lay Member, Camden CCG (Deputising for Glenys

Thornton) GP Representatives Dr Dina Dhorajiwala Governing Body GP Member, Haringey CCG Dr Dominic Roberts Clinical Director, Islington CCG (and representing both Camden

CCG and Enfield CCG) Dr Ash Bansal Governing Body GP Member, Barnet CCG Officer Representatives Ms Sarah McDonnell -Davies

Deputy Chief Operating Officer and Director of Primary and Community Care, Camden CCG

Ms Neeshma Shah Director of Quality & Clinical Effectiveness, Camden CCG Mr Paul Sinden NCL Director of Performance, Planning and Primary Care Daniel Glasgow Deputy Director of Primary Care Transformation (deputising for

Colette Wood, Barnet CCG) Mr John Piesse Head of Primary Care Commissioning, Enfield CCG (deputising for

Deborah McBeal, Enfield CCG) Ms Rebecca Kingsnorth Assistant Director of Primary Care, Islington CCG (deputising for

Clare Henderson, Islington CCG) Practice Nurse Representative

Ms Charlotte Cooley Governing Body Practice Nurse, Camden CCG In Attendance Deborah Fowler Healthwatch Representative, Enfield Ms Tracey Lewis Head of Finance, Camden CCG Ms Vanessa Piper Head of Primary Care, NCL Primary Care Team Ms Su Nayee Assistant Head of Primary Care, NCL Primary Care Team Mr Phillip Richards Member of the Public Mr D Shepard Member of the Public Ms Vivienne Ahmad (Minutes)

Board Secretary, Islington CCG

Apologies: Dr Charlotte Benjamin Governing Body GP Member, Barnet CCG Dr Mateen Jiwani Governing Body GP Member, Enfield CCG

221221

Item 3:

Page 2 of 6

Dr Kevan Richie Governing Body GP Member, Camden CCG Ms Glenys Thornton Governing Body Lay Member, Camden CCG Ms Karen Trew Governing Body Lay Member, Enfield CCG Mr Simon Goodwin Chief Finance Officer, NCL CCGs Mr Greg Cairns Director of Primary Care Strategy, London wide LMCs Ms Colette Wood Director of Care Closer to Home, Barnet CCG Ms Deborah McBeal

Director of Primary Care Commissioning and Deputy Chief Operating Officer, Enfield CCG

Ms Clare Henderson Director of Commissioning, Islington CCG

1. Welcome & Apologies 1.1 The Chair welcomed everyone to the meeting.

On becoming Barnet CCG Chair Charlotte Benjamin Barnet CCG had stepped down from the Committee and clinical representation on the Committee for Barnet CCG would be taken on by Dr Aash Bansal and Dr Murtaza Khanbhai who were the Primary Care leads on the CCG Governing Body. Dr Bansal was in attendance for this meeting. Haringey & Islington CCGs had separated the joint Director of Commissioning function with Clare Henderson and Rachel Lissauer now representing Islington and Haringey respectively on the Committee. Rachel Lissauer had given apologies for this meeting and Paul Sinden would cover for her.

1.2 Apologies were recorded as above. 2a

Declarations of Interests Register

2a.1 The Declarations of Interest Register was considered. There were no changes / updates declared.

2b Declarations of Interest Relating to Items on the Agenda 2b.1 There were no declarations declared pertaining to the agenda. 3 Minutes of the of the previous meeting held on 21 February 2019 3.1

The minutes were APPROVED as an accurate record of the meeting subject to the following amendment: • Charlotte Cooley had attended the meeting rather than given apologies. The Committee then asked for recruitment to the external clinical posts as per the Committee Terms of Reference, over and above the current practice nurse member, to progress.

3.2 Action: • Amend attendance list in the minutes for 21 February 2019. (Vivienne Ahmad);

3.3 Action: • Update on recruitment to the external clinical posts as set out in the Terms of

Reference. (Paul Sinden) 4 Actions from the previous meeting held on 21 February 2019 4.1

The action log was reviewed and updated.

5 Matters Arising 5.1 There was a hold sending out the contractual request for information to practices who

close half day due to the guidance published within the Primary Care Network Direct Enhanced Service (DES). Therefore, a revised letter was being sent to these practices reflecting the PCN guidance. An update (written or verbal) would be provided to the Committee in June 2019.

222222

Item 3:

Page 3 of 6

6 Questions from the public 6.1 In response to questions from the public the Committee confirmed that:

• The merger of the three practices working from East Barnet Health Centre approved by the Committee in February 2019 did not involve a site closure as the practices were already co-located in the health centre;

• The number of practices in NCL that did not have adequate half-day closure arrangements in place was 36 rather than 37 quoted in the February 2019 paper to the Committee. Twelve practices now had adequate arrangements in place leaving 24 practices where further work was being undertaken to put appropriate arrangements in place.

6.2 The Committee had also received a written question in advance linked to the item 10 on

the NHS Long Term Plan and National GP Contract in the Committee papers for 21 February 2019. The question was - Could the North London Partners advise what STP-wide engagement is planned in regard to ICS? The written response to the question highlighted that • NCL was in the early stages of designing what local integrated care systems (ICS)

would look like and how they would serve local communities; • Development and design would be informed by a series of prototyping workshops

held at both north central London and borough level between November 2018 and February 2019;

• Ensuring that resident and patient views and opinions were heard and considered through the design process would include establishing an NCL Engagement Board (final name to be determined) and an Online Engagement Hub;

• The NCL Engagement Board met for the first time on 16 April 2019, with membership including CCG lay members, representatives from voluntary and community sector organisations, local authority lead members for health, and NCL Healthwatch;

• The online engagement hub would launch in the second half of 2019, and would be a demographically representative online engagement platform, allowing NCL health and care organisations to hear the views and experiences of local residents and patients as they developed plans for integrated care systems;

• Work would continue with partner organisations CCGs, providers, local authorities, GP federations, Health and Wellbeing Boards and the NCL Joint Health Overview and Scrutiny Committee to utilise their local knowledge in developing plans.

ITEMS FOR DISCUSSION 7 Finance Report – Month 11 of 2018/19

7.1 Tracey Lewis presented the month 11 (February 2019) report, highlighting:

• A net underspend of £0.3m across delegated and CCG primary care budgets; • Delegated budgets were forecast to overspend by £2m accruing from the pressure

on Camden budgets; • Other costs included indemnity, occupational health, and locum costs were forecast

to overspend by £2m as at month 11. The pressure accruing from Haringey CCG was overstated and would be addressed by a budget virement for month 12 reports;

• These overspends were offset by underspends on primary care prescribing (£3.3m) and locally commissioned services (£0.7m). The pressure on short stock drugs was not included in the report (pressure held centrally by CCGs) with the exception of Enfield CCG where the pressure was included.

7.2 In response to the report the Committee:

• Asked why there was a pressure on the out-of-hours budget for Enfield CCG when overall spend in NCL was within budget, and CCGs had agreed additional in-year

223223

Item 3:

Page 4 of 6

funding for the integrated urgent care service during 2018/19. This would be addressed for 2019/20 budgets including assessing the original budget disaggregation across the CCGs;

• Requested that reporting of locally commissioned services (LCS) expenditure was consistent, and shown as a separate item, across the CCGs following Barnet CCG merging LCS expenditure into delegated budgets;

• Asked that the impact of Personal Medical Services (PMS) commissioning intentions for 2019/20 in moving towards equal allocations across all practices was set out in the report to the Committee for June 2019;

• Were informed that staff vacancies would not impact on payments to practices, as payments were made on a capitated (list size) basis;

• Were informed that the pressure on Camden CCG delegated primary care budgets accrued from the national allocation (based on population projections made in October 2015) not covering current list sizes or other pressures including premises cost premiums and developments;

• All CCGs had practice list sizes in excess of resident populations which presented a risk for the list cleansing process.

7.3 The Committee NOTED the report. 8 NCL Quality & Performance Report 8.1 The Committee received an overview of the report based on the latest information from

NHS England as at February 2019: • Each CCG showed a reduction in list size from February 2019 and this would be

clarified with NHS England; • The Committee would receive a report on CCG roles in supporting practice identify,

report and learn from serious incidents once guidance from NHS England had been received;

• Across NCL, as at February 2019, there were now 4 practices with 'inadequate' rating and 3 practices which had 'requires improvement' rating from the Care Quality Commission. Six practice were yet to receive their CQC inspection compared to 12 in October 2018;

• A meeting was taking place on 24 April 2019 to develop and early warning system for struggling practices across NCL, building on work undertaken in individual CCGs;

• The report now included Quality Outcomes Framework (QOF) scores for 2017/18, with overall results similar to the two prior years. Each CCG had practices with materially lower QOG achievement compared to their peers. Analysis indicated that low QOF scores did not necessarily translate into low CQC ratings;

• Overall patient experience ratings, as measured by the national IPSOS MORI survey, were consistent across the five CCGs, but there were slightly lower satisfaction levels in Barnet and Enfield for telephone access;

• The rates of complaints remained consistent across NCL with most resolved locally by practices before any escalation to NHS England particularly in Camden. NHS England were compiling a report on complaints themes that would be shared with the Committee once complete;

• Information on the impact of deprivation had been updated. The message remained the same in that impact was on differential access particularly for the use of digital services rather than on the quality of services provided by practices.


• Requested an evaluation of the actions set out in section three of the report in improving the quality of services including access;

• Requested that the outcome of the meeting to develop the early warning system for struggling practices be shared;

• Noted that practices with “inadequate” or “requires improvement” Care Quality Commission ratings were currently subject to formal remedial action.

224224

Item 3:

Page 5 of 6

8.3 Action: • To clarify if the reported list size reductions in the report for February 2019 were

accurate with NHS England. (Paul Sinden).

8.4 Action: • To update the Committee on the outcome of the meeting to develop the early warning

system for struggling practices. (Paul Sinden)

8.5 The Committee NOTED the report.

ITEMS FOR DECISIONS Contract Variations

9 All Boroughs – Personal Medical Services (PMS) Contract Changes

9.1 ENFIELD - Forest Road Group Practice, Riley House Surgery, Freezywater PCC,

Southbury Surgery, Green Street Surgery, Lincoln Road Medical Practice, Enfield Island Surgery and Dean House Surgery (Medicus Health Partnership)

9.1.1 The Committee was asked to approve the removal of a retiring GP as a signatory to the PMS agreement. A smooth transition would be secured through the GP working as a salaried GP for six months and coverage of session by other GP partners.

9.1.2 The Committee APPROVED the recommendation. 9.2 ENFIELD - Boundary House Surgery 9.2.1 The Committee was asked to approve retrospectively the removal of a GP as a signatory

to the PMS agreement. 9.2.2 The Committee APPROVED the recommendation. 9.3 CAMDEN - Regents Park Practice 9.3.1 The Committee was asked to approve the removal of a GP partner and the addition of

a new GP partner addition as a signatory to the PMS agreement. The practice worked in partnership with Ampthill Practice (General Medical Services contract).

9.3.2 The Committee APPROVED the recommendation. 9.4 CAMDEN - Prince of Wales Practice 9.4.1 The Committee was asked to retrospectively approve the removal of 3 GPs and addition

of 2 new GPs as signatories to the PMS agreement. Access levels would be maintained. 9.4.2 The Committee APPROVED the recommendation. 9.5 HARINGEY - Middleton Road 9.5.1 In February 2019 the Committee approved the addition of a new GP as signatory to the

PMS agreement. The GP then withdrew their application before the agreement was signed. The practice was seeking to find and add a new partner to the PMS agreement. Recruitment would allow the practice to put in place adequate cover arrangements for half-day closing.

9.5.2 The Committee APPROVED the recommendation. 10 BARNET - Cricklewood Health Centre - APMS Contract 10.1 The Committee was asked to approve the extension of the current Alternative Personal

Medical Services (APMS) contract to 30 November 2019 (with an option to 31 March 2020 in case of slippage on the procurement process) from the current end date of 30 September 2019. The extension would align with the CCG timeline for finalising the options appraisal and subsequent consultation process for the Walk in Centre. The consultation was planned to commence in April 2019 for the registered list and walk in centre, with the outcome and recommendation coming to the Committee in August 2019 for approval.

10.2 The Committee APPROVED the recommendation.

225225

Item 3:

Page 6 of 6

11 HARINGEY - Tottenham Hale Medical Centre - PMS Contract 11.1 The Committee was asked to approve the extension of the Tottenham Hale Medical

Centre contract until 25 June 2020 so that any procurement aligned with timescales for the development of new premises for the practice to relocate into. The contract was set up from a zero list in July 2016 in response to poor access in the area, and had grown to 2,700. If the contract was not extended the list would have to be dispersed or expensive caretaking costs incurred.

11.2 The Committee APPROVED the recommendation. 12 HARINGEY – Staunton Group Practice - caretaking APMS contract extension 12.1 The Committee was asked to approve extending the current caretaking arrangements

run by Federation4Health at Staunton Group Practice until 24 July 2019. This would provide continuity of care for patients registered at the Practice whilst Commissioners planned for the long term future of the Practice. The list, 14,254 patients, had begun to grow again in response to the successful caretaking arrangements.

12.2 The Committee APPROVED the recommendation to extension of the caretaking contract provided by Federated4health at Staunton Group Practice until 24 July 2019.

ITEMS TO NOTE - URGENT DECISIONS TAKEN SINCE 21 February 2019 13 Item to Note – Urgent Decision taken Since 21 February 2019 13.1 None taken.

ITEMS TO NOTE AND INFORMATION 14 PCCC Risk Register 14.1 Paul Sinden presented the paper summarising actions to address the risks falling within

the remit of the Committee: • The Committee would receive a report on workforce in August 2019 including the

impact of new GP contract; • The procurement for special allocation services was approved by the Committee in

February 2019; • Capita had started the list cleansing process for general practices; • The meeting to start development of the early warning system for struggling practices

had taken place on 24 April 2019.

14.2 In response to the report the Committee made the following comments and questions: • Requested the timescale for the list cleansing process run by Capita; • Noted that alongside the list cleansing process there were cohorts of people in NCL

not registered with a practice; • Noted the ongoing concern with the effectiveness of the Capita service as set out in

the audit report of the service. 14.3 Action:

• To provide the timeline for the Capita list cleansing process. (Vanessa Piper). 14.4 The Committee NOTED the risk report.

15 Committee Forward Planner 15.1 The Committee NOTED the forward planner. 16 Any other Business 16.1 No further business was discussed. 17 Date of next meeting 17.1 Thursday 20 June 2019, 3pm to 4:30pm in the Clerkenwell Room, 2nd Floor,

Laycock Centre, Laycock Street, London N1 1TH.

226226

Page 1 of 9

NORTH CENTRAL LONDON PRIMARY CARE COMMITTEE IN COMMON (Meeting held in public)

DRAFT Minutes of the Meeting held on Thursday 20 June between 3pm and 4:30pm

Clerkenwell Room, Second Floor, Laycock Centre, Laycock Street, London N1 1TH. Present: Voting Members: Ms Cathy Herman (Chair) Governing Body Lay Member, Haringey CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG Mr Ian Bretman Governing Body Lay Member, Barnet CCG Ms Glenys Thornton Governing Body Lay Member, Camden CCG Ms Karen Trew Governing Body Lay Member, Enfield CCG GP Representatives Dr Dina Dhorajiwala Governing Body GP Member, Haringey CCG Dr Dominic Roberts Clinical Director, Islington CCG Dr Murtaza Khanbai Governing Body GP Member, Barnet CCG Dr Kevan Richie Governing Body GP Member, Camden CCG Dr Mateen Jiwani Governing Body GP Member, Enfield CCG (outgoing GP

Representative for Enfield CCG) Dr Janet High Governing Body GP Member, Enfield CCG (incoming GP

Representative for Enfield CCG) Officer Representatives Ms Sarah McDonnell -Davies

Deputy Chief Operating Officer and Director of Primary and Community Care, Camden CCG

Ms Neeshma Shah Director of Quality & Clinical Effectiveness, Camden CCG Mr Paul Sinden NCL Director of Performance, Planning and Primary Care Ms Clare Henderson Director of Commissioning & Integration, Islington CCG Ms Rachel Lissauer Director of Commissioning & Integration, Haringey CCG Practice Nurse Representative

Ms Charlotte Cooley Governing Body Practice Nurse, Camden CCG In Attendance Deborah Fowler Healthwatch Representative, Enfield Ms Tracey Lewis Head of Finance, Camden CCG Tony Hoolaghan SRO for NCL Health & Care Closer to Home Programme & Chief

Operating Officer, Haringey & Islington CCGs (For Item 10) Katie Coleman GP Representative, Islington CCG & NCL Clinical Lead for Primary

Care and Health and Care Closer to Home for North London Partners (For Item 10)

Sarah Mcilwaine Programme Director, Health and Care Closer to Home, North London Partners (For Item 10)

Anthony Marks Senior Primary Care Commissioning Manager, Primary Care Team (deputising for Vanessa Price, Primary Care Team)

Daniel Glasgow Deputy Director of Primary Care Transformation (deputising for Colette Wood, Barnet CCG)

Peter Lathlean Deputy Head of Primary Care Commissioning, Enfield CCG (deputising for both Deborah McBeal & John Piesse, Enfield CCG)

227227

Page 2 of 9

Dr Dami Adedayo Nominated 2nd LMC Representative Mr Phillip Richards Member of the Public Ms Vivienne Ahmad (Minutes)

Board Secretary, Islington CCG

Andrew Tillbrook Deputy Board Secretary Apologies: Vanessa Price Head of Primary Care, Primary Care Team Ms Deborah McBeal

Director of Primary Care Commissioning and Deputy Chief Operating Officer, Enfield CCG

John Piesse Head of Primary Care Commissioning, Enfield CCG Colette Wood Director of Care Closer to Home, Barnet CCG Mr Greg Cairns Director of Primary Care Strategy, London wide LMCs

1. Welcome & Apologies 1.1 The Chair welcomed everyone to the meeting.

Apologies were received from Deborah McBeal and John Piesse from Enfield CCG (Peter Lathlean deputising), Colette Wood from Barnet CCG (Daniel Glasgow deputising), Vanessa Piper from the NCL Primary Care Team (Anthony Marks deputising) and Greg Cairns of the LMC (Dr Dami Adedayo deputising). Members were reminded to inform Vivienne Ahmad of any apologies in advance and identify a nominated deputy to ensure Committee quoracy was maintained. Dr Jiwani was thanked for his valuable contribution to the work of the Committee, as from August 2019 he would be replaced as the Enfield CCG clinical representative by Dr Janet High. Dr High was welcomed to the meeting.

1.2 Apologies were recorded as above.

2

Declarations of Interests Register

2.1 The Declarations of Interest Register was considered. There were no changes / updates declared.

3 Declarations of Interest Relating to Items on the Agenda 3.1 For item 10 on Primary Care Networks, GP members of the Committee working in

practices in North Central London (NCL) would have a conflict of interest and not be able to vote on formation of the networks. The Clinical Directors from Enfield and Islington CCGs who did not work in a practice within NCL would be eligible to vote. Dr High, as a locum working in the area, declared an interest in the requested partnership changes at Arnos Grove Medical Centre. The Chair declared an interest, as a patient, at Bounds Green group practice, and the Vice Chair would preside on item 12.7.

3.2 Action: • Declarations for Part I and Part II meetings from all practice representatives to be

updated for Primary Care Network (PCN) membership, including roles as Clinical Director, and if their practices were acting as a payee for a PCN. Vivienne Ahmad

4 Minutes of the previous meeting held on 18 April 2019 4.1

The minutes were APPROVED as an accurate record of the meeting subject to the following amendments in regards to attendance:

228228

Page 3 of 9

• Kathy Elliot was deputising for Glenys Thornton at this meeting. • To amend Mr Richards first name to Mr Phillip Richards as a member of public who

attended. 4.2 Action:

• To amend the minutes for the meeting held on 18 April 2019 as per Section 4.1 above. Vivienne Ahmad.

5 Actions from the previous meeting held on 18 April 2019 5.1

The action log was reviewed and updated. The committee requested that the action log be streamlined and duplicate actions be removed.

6 Matters Arising 6.1 None

7 Questions from the public 7.1 The Committee had received four questions in advance and responses were attached

to the CCG website alongside the Primary Care Committee papers for 20 June 2019. The Committee received further questions at the meeting: • Definition of 'stakeholder' - In regards to the Online Engagement Hub, clarity was

sought on the definition of 'stakeholders' to be consulted; • Deputation - It was confirmed that the Committee Terms of Reference would be

updated to allow for deputations from patients and the public? Terms of Reference would be reviewed annually and future iterations would be informed by input from Healthwatch.

7.2

Action: • To clarify the definition 'Stakeholders' to be consulted through the Online Engagement

Hub. Francesca McNeil. 7.3 Action:

• To bring back the Terms of Reference to the Committee including deputations and further updates on the PCCC membership. Andrew Spicer.

ITEMS FOR DISCUSSION 8 Finance Report – June 2019/20

8.1 The finance report provided an overview of budgets for 2019/20:

• There was a £9.5m (4.3%) uplift to the delegated commissioning allocation for NCL CCGs in 2019/20 compared to 2018/19, with the uplift covering the establishment of primary care networks (PCNs);

• The cost pressure on Camden delegated budgets (£1.9m) remained in place, with the pressure accruing from an underestimate of the population used for allocations compared to recorded registered list sizes;

• The funding uplift would need to cover demographic growth (expected increase in list sizes), with growth ranging from 3.2% for Camden and 1.1% for Haringey.

8.2 In response to the report the Committee: • Noted that registered list sizes may be inflated due to delays in the Capita-run list

cleansing process, with the risk report setting out a high-level timeline for the process; • Requested that future reports provide an overview of overall primary care budgets

(delegated and CCG funded) as for 2018/19 reports, a comparison against prior year spend by CCG, a breakdown of expenditure by Primary Care Network (PCN), and the level of deprivation (as measured by weighted population compared to resident population);

• Requested that reporting, and categorisation of expenditure be consistent across the CCGs as per actions agreed at the April 2019 Committee. To support this, a meeting on uniformity of reporting across the CCGs was being held on 24 June 2019.

8.3 Action:

229229

Page 4 of 9

• To update the finance report Finance for August 2019 in line with the Committee requests in Section 8.2 above. Tracey Lewis.

8.4 The Committee NOTED the report. 9 NCL Quality & Performance Report 9.1 Paul Sinden presented the Quality and Performance report highlighting:

• NHS England had discontinued production of the report but it would be reproduced locally from August 2019. Future reports would also provide a summary by Primary Care Network as well as by CCG;

• A high-level 'Themed Reviews of Complaints during 2018/19', had been received from NHS England (as requested by the Committee) categorising complaints for process problems including booking appointments and communications, about staff, and for complaints about clinical care including late or misdiagnosis;

• Work to develop an Early Warning System for struggling practices in NCL following a meeting held on 24 April 2019. This included an overview of work to date including resilience programmes and a themed review of practices with poor Care Quality Commission ratings in Haringey, the development of a set of principles to underpin the early warning system, the identification of triggers for support to be offered, and the development of support scenarios based on the nature of the problem a practice was facing – e.g., finance/partnership;

• Actions accruing from the information in the report including responses to patient survey results, support to improve quality outcomes framework (QOF) scores, and remedial contract action where required;

• Guidance on the role of CCGs in responding to serious incidents in general practice had yet to be published by NHS England.

9.2 In response to the report the Committee: • Identified the opportunity to use more up to date information if the report was to be

produced locally; • Requested that future reports provide a summary for each Primary Care Network; • Identified further triggers for the Early Warning System including non-participation in

protected learning time sessions and practice manager meetings, practices with inactive patient and public participation groups, practices not providing adequate cover arrangements for any half-day closures, ,and practices with high staff turnover;

• To get an accurate picture of practice performance information from a variety of sources should be triangulated and not rely on a single source such as Care Quality Commission ratings.

9.3 Actions: • Future reports to incorporate performance by Primary Care Network. Paul Sinden; • Report to be produced locally for meeting on 22 August 2019. Paul Sinden & Anthony

Marks; • Greater granularity on NHSE themed review of complaints. Vanessa Piper; • Additions to early warning system suggested by Healthwatch. Paul Sinden; • CCG work with practices on improving patient experience into August 2019 report.

CCG Reps.


10 Primary Care Networks (PCNs) - paper for approval 10.1 All GP Representatives working in NCL practices had a conflict of interest with

this item, so would not take part in any voting to approve the network proposals. It was noted this paper was for ‘APPROVAL’ rather than discussion. In line with the Committee-in-Common format approvals would be made borough-by-borough by respective CCG voting members (the relevant CCG Lay Member, Management Lead

230230

Page 5 of 9

and an independent clinician -Dr Mateen Jiwani for Barnet and Enfield CCGs and Dominic Roberts for Camden, Haringey and Islington CCGs). The Committee then received an overview of the proposals for forming Primary Care Networks (PCNs) in NCL: • PCNs were a central part of the new GP Contract introduced in April 2019, bringing

practices together to work in networks representing the most significant change for general practice since 1948 and the introduction of the NHS;

• PCNs would be composed of groups of practices working with health and care teams to provide integrated services to local residents;

• Introduction of the PCNs was facilitated by recurrent funding received through the Directed Enhanced Services (DES) developed as part of the new GP contract;

• Through the DES each PCN receive funding for a clinical director, and for additional staff to help deliver seven nationally mandated specifications from NHS England over the next five years;

• In 2019/20 payment to networks through the DES will focus on practices agreeing to work collaboratively and join a network, starting to recruit additional workforce and delivering against extended hours requirements. Delivery of requirements for 2019/20 and the future service specifications would need collaborative work with other local health and care providers;

• In NCL establishing the PCNs had been a unified and collaborative process with practices, GP Federations and the Local Medical Committee, and built on previous collaborative work in developing care and health integrated networks;

• This unified and collaborative approach had allowed practices and NCL CCGs to meet the tight national timetable for practices to submit their PCN registration form (choice of PCN) by 15 May 2019, identify a clinical director and payee organisation for each network, run preparatory workshops and a local approval process in each CCG (with Local Medical Committee representation) to make recommendations to the Committee-in-Common, and establish the Primary Care Networks by the end of June 2019;

• Practices had responded positively and effectively to the timetable for establishing the Primary Care Networks;

• Local proposals for the networks across NCL met national requirements and guiding principles for being geographically coherent, network population size (guide to cover between 30,000 – 50,000 people). Formation and composition of the networks had been agreed collaboratively with practices and stakeholders (practice membership of a network was voluntary rather than mandatory);

• All practices in NCL wanted to be part of a network, and proposals received covered the vast majority of NCL practices. Network arrangements for three practices were being finalised, with these practice being the two specialist primary care practices based in Camden (the Special Allocations Service and the Camden Health Improvement Practice), and in Haringey one practice was not yet aligned to a network. Camden CCG were working with NCL and regional teams to support solutions for the two specialist primary care services. In Enfield one practice had asked to move network after Committee papers were circulated;

• The number of networks proposed were Barnet (7), Camden (7), Enfield (4), Haringey (8), and Islington (4);

• Next steps for developing Primary Care Networks (PCNs) included: Working with the Local Medical Committee to develop processes to manage

conflicts of interest accruing from establishing the networks including transparency of funding flows;

Ensuring all NCL CCG Governing Body members updated their declarations of interest for respective Governing Bodies and Committees to include PCN membership, whether their practice was a PCN payee, and taking on any PCN clinical director roles;

Developing a process for review and approval of any changes to PCN configurations.

231231

Page 6 of 9


• Were informed that the NCL GP contract group was a time-limited task and finish group established to support introduction of the new GP contract and formation of the Primary Care Networks (PCNs);

• Requested that the process for changing future PCN configurations be brought to the next Committee in August 2019 for approval, as payments to the networks would commence from 1 July 2019. From the point at which PCNs were approved practices wanting to change network would need to give six months’ notice will be required;

• Requested guidance on its role and accountability for oversight of the Networks – for quality and performance, for finance and transparency of funding flows, for supporting vulnerable practices, and ensuring the avoidance of conflicts of interest;

• Were advised that as part of the process, each primary care network is expected to advise if they have completed all the schedules that sit behind the PCN agreement;

• Were informed that to manage potential conflicts of interest where some PCNs had selected GPs in NCL CCG Governing Body roles as their Clinical Director, the conflicts of interest guardian from the relevant CCG (usually the chair of the Audit Committee), the NCL CCG Accountable Officer, and the CCG Chief Operating Officer, would review the appointment on a case by case basis, making any appropriate adjustments to Governing Body roles. Such joint roles would be less likely post any merger of NCL CCGs. National advice had also been sought on this issue;

• Noted that PCNs were different sizes across NCL, and where network populations were above the 50,000 recommended ceiling in the national guidance, localities had been formed within the networks to comply with the 30,000 to 50,000 recommendation population size for grouping practices and health and care services. This had happened in Enfield to accommodate the Enfield super-partnership within a single PCN and maintain the recommended population base to align services;

• Were informed that practices could only be a member of one Primary Care Network even when the practice sat on borough boundaries as the core of networks was based on registered populations;

• Acknowledged and appreciated the work undertaken locally to establish the PCNs.

10.3 Barnet - the Barnet members of the Committee APPROVED the Barnet PCN Proposals.

10.4 Camden – the Camden members of the Committee APPROVED the Camden PCN Proposals.

10.5 Enfield – the Enfield members of the Committee APPROVED the Enfield PCN Proposals.

10.6 Haringey – Noting the requirement to support placement of the final practice, the Haringey members of the Committee APPROVED the Haringey PCN Proposals.

10.7 Islington - The Islington members of the Committee APPROVED the Islington PCN Proposals.

10.8 Action: • A paper on the process for managing any changes to Primary Care Network

membership and on the assurance role of the Committee with regards to the Networks to come to the Committee in August 2019. Sarah Mcilwaine and Paul Sinden

11 Learning from the GP Patient Survey

11.1 This item responded to an action accruing from the Committee review of patient survey

results earlier in 2019, with the Committee seeking assurance that CCG teams were working with practices in response to the survey results, and that where poor survey

232232

Page 7 of 9

results triangulated with other signs of a practice that might be struggling what support was being given.

11.2 Action: • Each CCG to provide a summary of work undertaken in response to patient survey

results within the Quality and Performance Report for the Committee in August 2019. CCG representatives.


ITEMS FOR DECISIONS Contract Variations

12 All Boroughs – Personal Medical Services (PMS) Contract Changes

12.1 ENFIELD - Forest Road Group Practice, Riley House Surgery, Freezywater PCC,

Southbury Surgery, Green Street Surgery, Lincoln Road Medical Practice, Enfield Island Surgery and Dean House Surgery (Medicus Health Partnership- MHP)

12.2 ENFIELD - Bush Hill Trinity 12.2.1 The Committee was asked to consider the addition of the practice (on a general medical

services contract with two GP partners) to the Medicus Health Partnership (MHP). The Committee did not approve the addition, as further work was required with MHP to ensure that the alignment of practices within the existing partnership better reflected the longer term strategic needs of general practice in Enfield. Work would be undertaken with MHP and the practice to find a solution.

12.2.2 The Committee DID NOT APPROVE the addition of the practice to Medicus Health Partnership.

12.3 ENFIELD - Arnos Grove Medical Centre 12.3.1 The Committee was asked to approve the removal of a GP partner and the addition of

a new GP partner as signatories to the practice Personal Medical Services (PMS) agreement. Approval would be subject to the practice addressing the shortfall in GP and nurse sessions (with the new GP partner addressing the former), and assurance that the additional clinical capacity was utilised. The Committee further requested that the CCG work with the practice to improve the nursing cover.

12.3.2 The Committee APPROVED the recommendation. 12.4 CAMDEN - Grays Inn Road Medical 12.4.1 Dr Kevan Ritchie stated his conflict of Interest in this item in regards to PCNs and

instead Dominic Roberts would vote on this item. The practice requested a contract variation to extend practice opening hours to meet to cover arrangements for half-day closures (the practice would now be open).

12.4.2 The Committee APPROVED the recommendation. 12.5 HARINGEY - Myddleton Road 12.5.1 The Committee was asked to approve the addition of one GP and one non-clinical

partner (the practice manager) to the practice Personal Medical Services (PMS) agreement. The new GP partner would enable benchmark appointments to be met and end the practice half-day closure.

12.5.2 The Committee APPROVED the recommendation.

12.6 HARINGEY - Tynemouth Road Health Centre 12.6.1 The Committee was asked to approve the removal of a GP from the partnership

agreement leaving two remaining GP partners. The approval was retrospective and effective from 1 May 2019. The practice was recruiting two salaried GPs and a clinical pharmacist to maintain access.

233233

Page 8 of 9

12.6.2 The Committee APPROVED the recommendation. 12.7 HARINGEY - Bounds Green Group Practice 12.7.1 The Committee was asked to approve the addition of two GPs to join the contract in

August 2019 to replace a retired GP and meet the needs of a growing list. Assurance was being sought that the practice was delivering on clinical capacity and room utilisation, with the former being addressed by reducing time per appointments from 15 to 10 minutes thereby increasing appointments offered

12.7.2 The Committee APPROVED the recommendation. 12.8 HARINGEY – Somerset Gardens Family Health Centre 12.8.1 The Committee was asked to approve the 24-hour retirement of one GP partner, with

six GP partners remaining. A new GP partner would be recruited to ensure benchmark clinical capacity was in place.

12.8.2 The Committee APPROVED the recommendation. 12.9 BARNET - Millway Medical Practice 12.9.1 The Committee was asked to approve the retirement of one GP partner, with seven GP

partners remaining. Benchmark clinical capacity was in place supported by seven salaried GPs, three GP registrars, and three locums

12.9.2 The Committee APPROVED the recommendation. 13 ENFIELD - Moorfield Road Health Centre - request to relocate to Riley House

Surgery 13.1 The Committee was asked to support the relocation of the practice, from its present site,

which was owned by NHS Property Services and at the end of its useful economic life, to Riley House Surgery at the end of August 2019. Riley House Surgery had been identified as the preferred site through an options appraisal as it offered opportunities for collaboration with another practice through co-location, a reduction in annual rent of £38k (offset initially by one-off £10k relocation costs), proximity to the current site for the practice patient list, and fit with the strategic estates plan for Enfield CCG. The practice would send a letter to their patient list given the short timeframe for the relocation.

13.2 The Committee APPROVED the recommendation. 14 HARINGEY - Bounds Green Group Practice - Application to Reduce Practice's

Outer Boundary Area 14.1 The Vice Chair presided over this item as the Chair declared an interest as a

patient at the practice. The Committee was asked to approve the practice request to reduce their boundary area due to an increasing list and future growth anticipated from nearby housing developments. The practice was in Haringey and the boundary reduction requested removed parts of nearby Enfield from its catchment area. Existing patients, and their family members, now falling outside of the reduced catchment area would not be removed from the practice list. Neighbouring practices from Haringey and Enfield, and patients on the practice list had been consulted on the boundary reduction with no objections received, and local capacity in place at these practices for new patients. Assurance that the practice was meeting the recommended guidance on clinical capacity and room utilisation was required before the reduction in practice area could take effect.

234234

Page 9 of 9

For future practice boundary variations that crossed CCG boundaries approval from the second CCG should be sought before the variation was brought to the Committee.

14.2 Action: • Future contract variation reports to include practice Primary Care Network (PCN)

membership. All • Future practice boundary variations that cross CCG boundaries receive approval from

both CCGs before the variation is brought to the Committee. All

14.3 The Committee APPROVED the recommendation.

ITEMS TO NOTE - URGENT DECISIONS TAKEN SINCE 18 APRIL 2019 15 None taken.

ITEMS TO NOTE AND INFORMATION 16 PCCC Risk Register 16.1 Paul Sinden presented the paper summarising actions to address the risks falling within

the remit of the Committee. 16.2 In response to the report the Committee:

• Requested the addition of a risk to the Committee register relating to the establishment of Primary Care Networks incorporating governance risks (conflicts of interest) and alignment with Integrated Care Systems (ICS).

16.3 Action: • Addition of the risk relating to establishing Primary Care Networks (as per Section

14.2 above), with the risk falling within the remit of the Committee. Paul Sinden. 16.4 The Committee NOTED the risk report.

17 Committee Forward Planner 17.1 The Committee NOTED the forward planner. 18 Any other Business 18.1 The Committee requested further information on its role and accountability if the merger

of NCL CCG was undertaken.

18.2 Action: • To provide an update on the role of the Committee post any merger of NCL CCGs.

(Paul Sinden) 19 Date of next meeting 19.1 Thursday 22 August 2019, 3pm to 4:30pm at Enfield CCG, Committee Room,

Holbrook House, 116 Cockfosters Road, Barnet, EN4 0DR

235235

236236

Page 1 of 9

NCL CLINICAL COMMISSIONING GROUPS AUDIT COMMITTEE IN COMMON Meeting held on Wednesday 27 March 2019

Clerkenwell Room, Islington CCG, Laycock St, London N1 1TH

Present: Members (voting) Adam Sharples Chair of NCL Audit Committee in Common; Chair of Haringey CCG Audit

Committee; Member of Enfield CCG Audit Committee Catherine Herman Member of Haringey CCG Audit Committee Lucy De Groot Chair of Islington CCG Audit Committee; Member of Haringey Audit

Committee Sorrel Brookes Member of Islington CCG Audit Committee Richard Strang Chair of Camden CCG Audit Committee; Member of Islington CCG Audit

Committee Dr Birgit Curtis GP Member of Camden CCG Governing Body (for Dr Kevan Ritchie) Dominic Tkaczyk Chair of Barnet CCG Audit Committee; Member of Camden CCG Audit

Committee Ian Bretman Member of Barnet CCG Audit Committee Karen Trew Chair of Enfield CCG Audit Committee; Member of Barnet CCG Audit

Committee In Attendance Rob Larkman Interim Chief Finance Officer, NCL CCGs (for Simon Goodwin) Arati Das Deputy Chief Finance Officer, Enfield CCG Ian Porter Director of Corporate Services, NCL CCGs Andy Spicer Head of Governance and Risk, NCL CCGs Clive Makombera Risk Assurance Director, Internal Audit, RSM Erin Sims Local Counter Fraud Specialist, Internal Audit, RSM Joanne Lees External Audit, KPMG (part meeting) Fleur Nieboer External Audit, KPMG (part meeting) Berand Henning North East London Commissioning Support Unit (NEL CSU, for Sarah

Rothenberg) Simon Medlane NEL CSU (item 3.2) Dayo Adebari Information Governance and FOI Manager (DPO), NCL CCGs (item 3.2) Andy Simpson Board Secretary (Barnet CCG) and Secretary to NCL ACIC (minutes) Apologies Dr Jarir Amarin Member of Enfield CCG Audit Committee Dr Kevan Ritchie Member of Camden CCG Audit Committee Simon Goodwin Chief Finance Officer, NCL CCGs

1. INTRODUCTION 1.1 Welcome and Apologies 1.1.1 The Chair welcomed members and attendees to the meeting, noted the apologies

received and advised that all five individual audit committees were – and therefore the Audit Committee in Common was – quorate.

237237

Page 2 of 9

1.2 Declarations of Interests 1.2.1

No new or existing declarations of interests were made in the context of any agenda item.

1.3 Declarations of Gift and Hospitality 1.3.1

No declarations of gifts or hospitality were made.

1.4 Minutes of the Meeting held on the 16 January 2019 1.4.1 1.4.2 1.4.3

The minutes of the meeting held on 16 January were approved subject to the inclusion of the following paragraph within the Internal Audit Progress Report Section: Karen Trew stated that the amber-red risk rating of Enfield CCG’s internal audit on financial management was in part due to the adjustment of its forecast position at month six, which was prior to the audit being undertaken, whereas Barnet and Haringey CCGs had adjusted their forecast positions at month nine, after the audit had taken place. Clive Makombera responded to advise that the internal audit opinions of Barnet and Haringey CCGs would be subject to reconsideration in light of their year-end positions. Ms Trew added that relative wording within internal audit opinions for NCL CCGs should reflect their similar and shared challenges regarding QIPP, which was largely out of contract.

1.5 Action Log 1.5.1 1.5.2 1.5.3 1.5.4 1.5.5

Updates were given in relation to items open on the Committee Action Log, as follows: 16/01-005 – agree a NCL-wide protocol for reporting gifts and hospitality declarations Andy Spicer advised that it had been agreed that full registers of gifts and hospitality declarations would be submitted for review by ACIC twice yearly, and at all other committees across NCL there would be oral updates only. ACIC agreed to close the action. 16/01-008 – an update on management actions to address Capita control issues Rob Larkman advised that as the report on Capita internal controls (considered at the January 2019 meeting) was a third party assurance on a national issue, NCL CCGs were limited in regards to the direct action they could take in mitigation of the control issues it highlighted. However, NCL CCGs would seek assurance in relation to remedial actions implemented to address control gaps as part of the follow-up review, and work with NHSE to seek ongoing assurance beyond that review. Fleur Nieboer stated that the control gaps did not cause concern over external auditors’ ability to audit all financial values. Catherine Herman added that the risk was being given oversight by the NCL Primary Care Co-Commissioning in Common Committee, which had included it on the Committee’s risk register. ACIC agreed to close the action. ACIC agreed to close the following actions, which had either been provided with an written update or were covered by an agenda item at the present meeting:

• 19/07-004 – report on Islington CCG GP remuneration to be forwarded to its Audit Committee Lay Members;

• 10/10-002 – further consideration of SIRO arrangements at Enfield CCG, which differ from those of other NCL CCGs;

• 16/01/001 – a senior CSU representative (Sarah Rothenberg) to attend all future ACIC meetings;

238238

Page 3 of 9

• 16/01/002 – update on plans for future provision of CSU assurance, to replace the CSU Assurance Group. Mr Makombera advised that future assurance reporting will be included within internal audit progress reports, which will be supplemented with attendance by a senior CSU representative;

• 16/01-003 – an update to be provided in the implementation of outstanding procurement internal audit recommendations by the CSU;

• 16/01-004 – an update to provide assurance on the quicker implementation of audit recommendations to the CSU in future;

• 16/01-006 and 007 – the submission of 2018-19 tender waivers to Audit Committee Chairs for review, and the establishment of a NCL-wide process for the recording and reporting of them

• 16/01-009 – update to be provided on plans to conduct a NCL-wide GP practice list-cleansing exercise. Members noted the slow progress with this given the scale of associated issues, and raised concern about the restricted scope of the exercise, which focused on patients over a 100 years of age as well as overseas patients and multiple occupancy residencies;

• 16/01/010 – the inclusion within the Committee forward planner of reviews of NCL board assurance and risk management frameworks.

2. EXTERNAL AUDIT 2.1 External Audit Progress Report 2.1.1 2.1.2 2.1.3

Fleur Nieboer and Joanne Lees provided an overview of external audit work undertaken by KMPG since the January 2019 meeting, reporting the following key points:

• Interim audit work had been completed, which included the testing of core processes and controls across NCL CCGs and the CSU, from which no significant weaknesses had been identified;

• Work to review value for money arrangements across NCL, as well as testing of healthcare and other expenditure balances, had commenced;

A question was raised on whether forecast deficits across NCL caused concern for auditors either on value for money arrangements or for whether CCGs with deficits could continue to be considered as viable. In response, it was noted that the existence of deficits did form part of the assessments, but that this would not necessarily affect their viability as organisations. ACIC NOTED the External Audit Progress Report.

3. INTERNAL AND EXTERNAL CONTROLS 3.1 Tender Waivers 3.1.1 3.1.2

Ian Porter presented a new NCL-wide process for the recording and reporting of tender waivers, advising that the new process was designed to harness the good practice evident at some NCL CCGs and to establish consistency across NCL. The new process is consistent with the new NCL Standing Financial Instructions (SFI). In discussion of the proposed process, it was AGREED that thresholds would be included for Deputy CFOs to avoid the requirement that all waivers should be signed by the CFO. The Committee also agreed that the form templates should include:

• a section on why the waiver is being requested, including a drop-down menu with which the requestor chooses from the list of acceptable reasons and space to provide context;

239239

Page 4 of 9

3.1.3 3.1.4

• a prompt to ensure that advice has been sought from the Procurement Department, including in relation to risk; and

• the requirement for forms to be sent to senior members of NCL Corporate Services once they have received approval from the CFO or Deputy CFO.

It was suggested that tender waivers should be included within registers of procurement decisions. In response to a request by Dominic Tkaczyk, Andy Spicer undertook to send him a copy of Barnet CCG’s current SFIs. ACIC:

• NOTED the proposed tender waiver process; • AGREED amendments to the process and form template detailed at paragraph

3.1.2 (Action 27/03-001; Ian Porter); • AGREED that CCGs should send outstanding waivers to their respective Audit

Committee Chairs for review (Action 27/03-001; Ian Porter).

3.2 Information Governance Update and Cyber Security Report 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5

Dayo Adebari provided an update on NCL use of the Data Security and Protection Toolkit, advising that there had been significant improvements in comparison with the previous year, and reporting the following key points:

• The new Toolkit was more robust than the previous, and measured compliance with General Data Protection Regulations (GDPR);

• The recent toolkit submission from NCL CCGs demonstrated compliance with all 70 mandatory requirements, as well as 68 out of 69 non-mandatory requirements. The required compliance report to Senior Information Risk Owners (SIRO) across NCL was under production;

• Work was underway to ensure that all GPDR critical actions were implemented;

• Information asset registers and data flow mapping were under production and, as yet, no concerns had been raised.

Further concern was raised in relation to the SIRO arrangements at Enfield CCG which are inconsistent with those of other NCL CCGs (as detailed in action log item 10/10-002). In response, it was noted that there had been further discussion between NCL Corporate Services and the CCG, the result of which was an agreement that the Deputy Chief Operating Officer should continue to undertake the role of SIRO, rather than this sit with NCL Corporate Services, due to the requirement for SIROs to have a strong local presence within an organisation and a lack of capacity within Corporate Services to undertake this. In response to a question raised, it was noted that while NCL CCGs supported GP practices in their completion of and compliance with the toolkit, they had no enforcement role over practices. Simon Midlane introduced a report from the CSU on NCL cyber security arrangements. Members had read the report in detail, and raised concern about the stated five-month Care Computer Emergency Response Team reporting backlog. In response, Mr Midlane advised that this had been due to personnel change, and that the backlog had reduced since the report was produced. ACIC NOTED the Information Governance Update and Cyber Security Report.

240240

Page 5 of 9

3.3 Financial Services Report 3.3.1 3.3.2 3.3.3 3.3.2

Arati Das introduced a financial services report which provided an update on invoice purchase order compliance and aged debtor balances, advising that an updated purchase order level report from the CSU, covering all CCGs, had been included within a recirculation of meeting papers (the originally-circulated version had not covered all CCGs). Ms Das sought and received agreement at the meeting that in future such reports should always cover all NCL CCGs. Ms Das reported that the total value of trade receivables was at £9.2m, of which £2.6m was greater than one year old. £2.5m of it was inter-NCL CCG debt, which existed in part due to invoice approval issues following the implementation of a new approval mechanism designed to embed more rigorous checks in light of forecast deficits across NCL. Work was underway to improve and streamline the process in order to avoid future obstacles to invoice approval. Members stated that the Financial Services Report lacked sufficient narrative for them to provide proper scrutiny or support to NCL CCGs. A question had been raised on whether or not there was the appetite to write off any of the aged debt, and concerns were raised both about the decline in invoice purchase order performance at Haringey CCG and instances of purchase orders not being supplied for regular payments, but the report did not provide the narrative necessary for ACIC to consider these matters properly. There was consensus at the meeting that a combination of staff training and an automated system mechanism to prompt purchase order creation would help to improve compliance. Members asked that NCL finance teams and CSU procurement teams consider other ways in which purchase order compliance could be improved. ACIC:

• NOTED the Financial Services Report • AGREED that future iterations should provide greater narrative to explain

trends and declines in performance, along with management recommendations on actions to ACIC

• AGREED that the NCL CFO should provide a strong mandate to finance teams that invoices must not be paid without a purchase order, and for training to be provided wherever this is required;

• AGREED that Berand Henning would ensure that future purchase order compliance reports cover all NCL CCGs, and that invoice processing systems feature an automated prompt requiring staff to ensure that purchase orders have been created.

3.4 Governance Work Plan 3.4.1 3.4.2 3.4.3

Ian Porter introduced a progress report on delivery of the NLC Governance and Risk Team’s work programme, noting:

• Enfield CCG had recently approved a number of changes to its Constitution, and work was underway to redraft the Constitutions of all NCL CCGs;

• Significant focus had been given to the reviewing and redrafting of a number of NCL-wide corporate policies, which were included within the present meeting papers for approval;

• The annual reporting and account documentation production process had begun.

In discussion ACIC noted the urgency of work by finance and procurement teams to standardise processes and procedures across NCL. In reference to the recent directive from NHSE for CCGs to reduce running costs by 20% in time for the start of the 2020-21 financial year, members stated that it would be

241241

Page 6 of 9

3.4.4

important for Governing Bodies across NCL to be given the opportunity as soon as possible to review plans to enact it, and for members of ACIC to provide some oversight of the associated risks. ACIC:

• NOTED the Governance Work Plan • REQUESTED that audit committee chairs be engaged in consideration of the

governance implications of plans to reduce running costs, including the in-housing of CSU functions.

4. POLICIES 4.1 NCL Counter Fraud, Bribery and Corruption Policy 4.1.1 4.1.2 4.1.3

Andy Spicer presented the Draft NCL Counter Fraud, Bribery and Corruption Policy, for which NCL CCGs were seeking ACIC approval. He drew members’ attention to a handout showing an example of a process flow diagram depicting potential routes to recover losses from fraud, advising it would be included within the policy before it was published. Concern was raised over the requirement detailed within the policy for commissioners to assure themselves in relation to the rigour of providers’ counter fraud arrangements. Members had previously agreed not to support this change. Ian Porter advised that the requirement was a nationally-applied one and as such the wording of it within the policy could not be amended. In discussion, it was agreed that extra wording should be added to explain that CCGs would seek assurance that effective counter fraud arrangements were in place as part of their normal contractual relations with providers, but would not accept responsibility for policing those arrangements. ACIC:

• AGREED that future policy revisions should show clearly what has been amended since the previous version; APPROVED the NCL Counter Fraud, Bribery and Corruption Policy subject to amendment to reflect ACIC’s agreement at paragraph 4.1.2 (for all instances in which the requirement is referred to) (Action 27/03-002; Erin Sims)

4.2 NCL Conflicts of Interest Policy (incorporating Gifts and Hospitality) 4.2.1 4.2.2

Andy Spicer introduced a revised version of the NCL Conflicts of Interest Policy, which had been amended to incorporate a NCL-wide Gifts and Hospitality Policy. ACIC:

• APPROVED the Conflicts of Interest and Gift and Hospitality Policy; • AGREED that the wording of paragraph 6.1(d) should be amended to make it

clearer that it refers to clinical colleagues from member GP practices who are involved in commissioning.

4.3 NCL Standards of Business Conduct Policy 4.3.1 4.3.2

Andy Spicer introduced a revision of the NCL Standards of Business Conduct Policy, for which NCL CCGs were seeking ACIC approval. ACIC:

• APPROVED the NCL Standards of Business Conduct Policy pending amendments to paragraph 8.7 to state that individuals are encouraged not to lend to or borrow from colleagues, rather than that they must not (Action 27-03-003; Andy Spicer);

242242

Page 7 of 9

• AGREED that clarification should be provided on whether or not staff members are required to declare political associations when applying for roles (Action 27-03-003; Andy Spicer).

5. INTERNAL AUDIT 5.1 Draft Head of Internal Audit Opinions 5.1.1 5.1.2 5.1.3

Clive Makombera presented Draft Head of Internal Audit Reports for Barnet, Camden, Enfield, Haringey and Islington CCGs, advising that each of the CCGs has been categorised as having an adequate and effective framework for risk management, governance and internal control (amber-green). The following was noted in discussion of the reports:

• It would be valuable for ACIC to receive a report in six months’ time in order for the committee in common to review the extent to which the high and medium priority actions for Continuing Health Care (CHC) controls detailed within the reports would enable the desired improvements, and if they would support the establishment of a central CHC team. Mr Makombera responded that work had been underway to review potential collaborative arrangements but that there was not yet a plan in place. Members added that not all CCGs had approved the funding arrangements to support such collaboration, and as such there may not yet be the mandate to proceed;

• It was unclear in the report which management recommendations had been implemented and which were incomplete. Mr Makombera advised that there were no overdue management actions;

• The internal audit opinions should acknowledge explicitly that the distribution of risk across the system between commissioners and providers was disproportionate.

ACIC:

• NOTED the Draft Head of Internal Audit Opinions; • AGREED that the phrasing of financial management elements of the Enfield

report required reconsideration in order to reflect both the changes to the forecast position during the financial year, and the level of risk associated with the year-end position (Action 27-03-004; Clive Makombera)

• AGREED that a report would be presented in six months providing an update on the impact of work to drive CHC improvements;

• AGREED that a statement should be added to the reports which makes it clear that management action has been taken in all areas highlighted by auditors (Action 27-03-004; Clive Makombera)

• AGREED that Mr Makombera would ensure that internal audit opinions reflected the disproportionate distribution of risk across the system between commissioners and providers (Action 27-03-004; Clive Makombera).

5.2 Internal Audit Progress Report 5.2.1 5.2.2

Mr Makombera presented the NCL Internal Audit Progress Report, which provided an overview of performance in delivery of the Internal Audit Strategy and the outcomes of individual reviews, drawing members’ attention to the relevant issues for each CCG detailed within the cover sheet. The Chair raised concern that assessments of QIPP seemed to suggest that there was an unsustainable approach in place, and asked Rob Larkman how management had responded to this assessment. In response, Mr Larkman advised that a different approach had been adopted for the current round of contract negotiations. The approach had been to develop a commonly understood figure of target net growth

243243

Page 8 of 9

5.2.3 5.2.4

among system partners, as well as the associated level of QIPP delivery required by the system in order to achieve the desired level of net growth. The next steps would be for the system collectively to develop and deliver specific QIPP schemes accordingly. In response to a question raised on the reasons that NCL QIPP schemes seemed to be those with the greatest delivery shortfall, Mr Larkman advised that this was in part due to providers and commissioners arriving at differing assumptions for contract values. ACIC NOTED the Internal Audit Progress Report.

5.3 NEL CSU Internal Audit Progress Report 5.3.1 5.3.2 5.3.3

Mr Makombera presented the NEL CSU Internal Audit Progress Report, advising that internal audit reports had been finalised for procurement – which received partial assurance – and HR Support, which received reasonable assurance. Issues reported in relation to the procurement audit included the completeness of conflicts of interest documentation and level of clarity of roles and responsibilities between the CSU and the CCGs. Mr Henning advised that a service level agreement was under development in order to provide greater clarity on roles and responsibilities, and that there was confidence that conflicts of interest management processes had improved since the audit was conducted. ACIC NOTED the NEL CSU Internal Audit Progress Report.

6. COUNTER FRAUD 6.1 Local Counter Fraud Specialist (LCFS) Progress Report 6.1.1 6.1.2 6.1.3 6.1.4 6.1.5 6.1.6

Erin Sims introduced a report which provided a progress update of the Local Counter Fraud Team’s delivery of the NCL Counter Fraud Plan. Members had read the report in detail, and as such attention was drawn to the report’s summary of new counter fraud standards released by the NHS Counter Fraud Authority, which included a requirement for audit committee chairs and CFOs to sign-off the counter fraud team’s self-review tool submission. There was also a new requirement (standard 1.4) for quality risk assessments to be reviewed in line with the organisational risk registers and methodology. Due to the timing of the release of the standards it was anticipated that the majority of organisations would not be able demonstrate compliance, though the LCFT had undertaken to work with risk leads to ensure compliance. Ms Sims then provided an overview of fraud allegations and the processes undertaken to investigate them, agreeing to provide more information to Karen Trew in relation to Enfield case number CF/002445/18. The Chair stated that it was disappointing to see that investigations rarely resulted in prosecution or other forms of legal sanction, since these were valuable deterrents. In response to a request from Birgit Curtis, Ms Sims agreed to seek and provide information on instances in which allegations had been reported through the Care Quality Commission. ACIC NOTED the Counter Fraud Progress Report.

244244

Page 9 of 9

6.2 NCL Counter Fraud Plan 2019-20 6.2.1 ACIC:

• APPROVED the NCL Counter Fraud Plan 2019-10 • AGREED that future iterations of the report should make more explicit the level

of risk in relation to prescription fraud, given the significant sum of money spent by CCGs on prescriptions.

6.3 Fraud Risk Assessment Report 6.3.1 ACIC NOTED the Fraud Risk Assessment Report.

7. ITEMS FOR INORMATION 7.1 Committee Forward Planner 7.1.1

ACIC NOTED the forward planner.

7.2 Any Other Business 7.2.1 7.2.2

Ian Porter advised that the Camden CCG Governing Body has agreed to suspend the CCG's standing orders in order to extend the term of its Nurse Member by thirteen months. This decision had also been endorsed by the Camden CCG Audit Committee. ACIC AGREED:

• That minutes of its future meetings would be circulated to members as soon as they have been approved by the Chair, rather than wait for them to be included in the papers of the next meeting;

• That at each meeting, members would agree which matters discussed by ACIC they should raise with their respective Governing Bodies. For the present meeting, it was agreed that this would be discussions on CHC and QIPP.

7.3 Date of Next Meeting 7.3.3 Thursday 23 May, 09.00-11.00, Clerkenwell Room, Islington CCG

245245

246246

February 2018 Page 1 of 12

Jargon Buster (Acroynms Guide)

updated February 2019

Acronym Meaning A

AC Acute Care ACO Accountable Care Organisation ADD Attention Deficit Disorder ADASS Association of Directors of Adult Social Services ADHD Attention Deficit Hyperactivity Disorder AHSNC Academic Health Science Networks and Centres ALB Arm’s Length Body AoMRC Academy of Medical Royal College APHR Annual Public Health Report APMS Alternative Provider of Medical Services AQP Any Qualified Provider ASC Adult Social Care B

BAF Board Assurance Framework BAU Business as usual BC Business Continuity BCCG Barnet Clinical Commissioning Group BCDR Business continuity and disaster recovery BCF Better Care Fund BEHMHT Barnet, Enfield and Haringey Mental Health Trust BMA British Medical Association BMEC Black & Minor Ethnic Communities BNF British National Formulary BSCB Barnet Safeguarding Children Board C

C2C Consultant to Consultant CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CAP Common Assurance Process CBT Cognitive Behavioural Therapy CCG Clinical Commissioning Group CCU Critical Care Unit CG Caldicott Group (Information Sharing) CD Commissioning Development (National Director) CDS Commissioning Data Set CDF Cancer Drugs Fund CG Caldicott Guardian CEPN Community Provider Education Network CHC Continuing Health Care CHINs Care Closer to home Integrated Networks

247247


CHM Commission of Human Medicine CHSG Clinical Harm Steering Group CIEH Clinical Intake of Environment Health CIT Clinical Information Technology CKD Chronic Kidney Disease CMHT Community Mental Health Team CMT Controlled Medical Terminology COPD Chronic Obstructive Pulmonary Disease CPA Care Programme Approach CPAG Clinical Priorities Advisory Group CPRD Clinical Practice Research Datalink CQC Care Quality Commission CQOG Clinical Quality Oversight Group CQRG Clinical Quality Review Group CQUIN Commissioning for Quality and Innovation CROMS Clinical Reported Outcomes Score CRG Clinical Reference Group CSCN Clinical Senate & Clinical Networks CSIPS Continuous Service Improvement Plans CSO Commissioning Support Organisation (and NHS Providers) CSU Commissioning Support Unit CVD Coronary Vascular Disease CHD Coronary Health Disease D

DBS Disclosure & Barring Service DES Directed Enhanced Service DH or DoH Department of Health DNA Did not attend DOLS Deprivation of Liberty Safeguards (in Hospital) DPH Director of Public Health DR Disaster Recovery DTOC Delayed Transfer Of Care (where patients are ready to return home

or transfer to another form of care but still occupy a hospital bed) DVSG Domestic Violence Strategic Group E

EA Equality Analysis ECH Enhanced Care Homes E&D Equality and Diversity ED Emergency Department EDS Equality Delivery System EIA Equality Impact Assessment EMT Executive Management Team EOLC End of Life Care EQIA Equality Impact Assessment EPR Electronic Patient Record

248248


EPRR Emergency Preparedness Resilience Response F

FACS Fairer Access to Care Service FBC Full business case FFT Friends and Family Test FNC Funded Nursing Care FoI Freedom of Information FT Foundation Trust FRG & Q Financial Recovery Group & QIPP FTN Foundation Trust Network G

GBAF Governing Body Assurance Framework GDP Gross Domestic Product GIPs Guaranteed Income Payments (Social care) GMC General Medical Council GMS General Medical Services GP General Practice (or General Practitioner) GPC General practice Committee GPFV General Practice Forward View

H

HASC Health & Adult Social Care HCAI Health Care Acquired Infections HEART Health & Education Access & Resources Team HEE Health Education England HES Hospital Episode Statistics HHSAC Health, Housing & Adult Social Care HPA Health Protection Agency HPSS Health and Personal Social Services HoNOS Health of the Nation Outcomes Score HRTPF Human Rights Transition Partnership Forum HSCIC Health and Social Care Information Centre HSO Health Service Ombudsman HSSI Higher Severity Service Incident HWBB Health and Wellbeing Board HWE Health Watch England I

IAPT Improving Access to Psychological Therapies ICAS Independent Complaints Advocacy Service ICO Information Commissioner's Office ICP Integrated Care Pathway ICT Information and Communication Technology IFR Individual Funding Request IG Information Governance IHA Initial Health Assessment IHM Institute of Healthcare Management IAPT Improving Access to Psychological Therapies

249249


IDVA Independent Domestic Violence Advocates III Institute for Innovation & Improvement ILDS Integrated Learning Disabilities Services IMHA Independent Mental Health Advocacy IPC Integrated Personalised Commissioning IPCC Inspection Prevention & Control Committee IRP Independent Reconfiguration Panel ISBHaSC Information Standards Board for Health and Social Care ITT Invitation to Tender J

JCC Joint Commissioning Committee JCPMH Joint Commissioning Panel for Mental Health JGPITC Joint GP IT Committee JHWS Joint Health & Wellbeing Strategies JSNA Joint Strategic Needs Assessment K

KPI Key Performance Indicator L

LAC Looked After Children LA Local Authorities LAS London Ambulance Service LCFS Local Counter Fraud Specialist LCPW Liverpool Care Pathway LD Learning Disabilities LES Locally Enhanced Service LETBs Local Education & Training Boards LGA Local Government Association LHB Local Health Board LMC Local Medical Committee LHW Local Health Watch LINK Local Involvement Network LQSG Local Quality Surveillance Group LRO Legislative Reform Order LSP Local Service Provider M

MADEs Multi-Agency Discharge Events

MARAC Multi-Agency Risk Assessment Conference MCA Mental Capacity Act MD Medical Director MDT Multidisciplinary team MSKS Musculoskeletal Service ME Myalgic encephalomyelitis MHRA Medicines and Healthcare products Regulatory Agency MSA Mixed Sex Accommodation MCPs Multispecialty Community Providers MO Medically Optimised

250250


N

NAG National Advisory Group NCLSPG North Central London Strategic Planning Group NCLs National Clinical Leads NEL CSU North East London Commissioning Support Unit NES National Enhanced Service NHSE NHS England NHSPS NHS Property Services NHSE National Health Service England NHSCB NHS Commissioning Board NHSI NHS Improvement NHS IQ NHS Improving Quality NIB National Information Board NICA National Integration Centre and Assurance NICE National Institute for Health and Care Excellence NIHR National Institute for Health Research NMUH North Middlesex University Hospital NPSA National Patient Safety Agency NQB National Quality Board NRLS National Reporting & Learning System NSF National Service Framework O

OBC Outline Business Case OBR Office of Budget Responsibility OOH Out of hours OP Older Person OPAU Older People’s Assessment Unit OPCMHT Older Persons Community Health Team OT Occupational Therapy P

PACE Post-Acute Care Enablement PACs Primary and Acute Care Systems PAET Patient Assessment Environmental Team PALS Patient Advice Liaison Service PAS Patient Administration System PC Primary Care PCSB Primary Care Strategy Barnet PD Physical Disabilities PDT Programme Delivery Team PH Public Health PID Person Identifiable Data PID Project Initiation Document PIMHS Patient Infant Mental Health Service

PLACE Patient-Led Assessment of Care Environment

PoLCE Procedures of Limited Clinical Effectiveness

251251


PPE Patient and Public Engagement PPI Patient and Public Involvement PRES Patient Recorded Experience Score PROS Patient Recorded Outcomes Score PPG Patient Participation Group PPV Patient & Public Voice

PROMS Patient Related Outcome Measures

PTL Patient Tracker List

PYLL Probable Years of Life Lost Q

QIA Quality Impact Assessment QIC Quality Improvement Care QIPP Quality, Innovation, Productivity and Prevention QISTs Quality Improvement Support Teams QOF Quality Outcomes Framework QSG Quality Surveillance Group R

RACI Responsible Accountable Consulted Informed RAID Rapid Assessment, Intervention and Discharge Service (a mental

health service) RAG Red Amber Green (traffic light rating system)

RCP Royal College of Physicians

RCGP Royal College of General Practitioners

RCT Randomised Controlled Trials

RCN Royal College of Nursing

RDAG Rare Disease Advisory Group

RHAs Referral Health Assessments/Review Health Assessments

RFL Royal Free London NHS Foundation Trust consisting of Barnet, Chase Farm and Royal Free Hospitals

RP Registered Provider RSL Registered Social Landlord RTT Referral to Treatment S

SAB Safeguarding Adults Board SBS Shared Business Services SCIE Social Care Institute for Excellence SHA Strategic Health Authority SHOT Serious Hazards of Transfusion SIs Statutory Instruments SI Serious Incident SLA Service Level Agreement SMT Senior Management Team

252252


SPA Single Point of Access SPG Strategic Planning Group SRG System Resilience Group SSCB Safer & Stronger Communities Board STP Sustainability and Transformation Partnership T

NHSTDA NHS Trust Development Authority TREAT Triage and Rapid Elderly Assessment Team TSDO Transformation Strategic & Delivery Office TTA Tablets to Take Away TUPE Transfer of undertaking protection of employment regulations TWR Two-week referral U

UCC Urgent Care Centre UCLH University College London Hospital UECP Urgent and Emergency Care Providers V

VAWG Violence Against Women & Girls VBC Value Based Commissioning VSNAG Voluntary Sector National Advisory Group W WHO World Health Organisation 2WW Two Week Wait

253253


Some of the Acronyms Explained: Acute services Medical and surgical treatment provided mainly in hospitals. Care pathway/patient pathway A care pathway (also sometimes called a patient pathway) is a diagram, drawn by healthcare professionals, of a patient's journey through care for a particular health condition. The pathway is developed so that, at each stage, the patient is getting the appropriate care. If that care does not work, the patient will continue on the care pathway to the next stage. Care pathways are designed to get the patient to the appropriate care smoothly. Barnet Clinical Commissioning Group (CCG) Barnet CCG is an NHS organisation that commissions (plans and buys) healthcare services for the residents of Barnet. CCGs were established under the government’s Health and Social Care Act 2012 and replaced Primary Care Trusts (PCTs). Barnet CCG is made up of all the GP practices in Barnet and is led by a Governing Body. Commissioning Commissioning in the NHS is the process of ensuring that the health and care services provided effectively meet the needs of the population. It is a cycle of work from understanding the needs of a population and identifying gaps or weaknesses in current provision, to procuring services to meet those needs. Commissioning intentions Commissioning intentions are developed every year. They describe the changes and improvements to healthcare that the CCG wants to make for the year ahead and what we expect to commission (or ‘buy’) to achieve these changes. The CCG’s commissioning intentions are shared widely with providers and stakeholders and are then developed into a commissioning strategy plan for the year ahead. Commissioning Support Unit (CSU) The Commissioning Support Unit (CSU) is an organisation which provides services to CCGs. CCGs can decide on the services they wish to obtain through CSUs e.g. commissioning, IT services, information analysis. The CSU providing services to Barnet CCG is NEL CSU. CQUIN

254254


CQUIN stands for Commissioning for Quality and Innovation. CQUIN is a payment framework which allows commissioners like Barnet CCG to link a proportion of providers' income to the achievement of locally agreed quality improvement goals. Healthwatch Barnet Healthwatch Barnet is the organisation established by the Health and Social Care Act 2012. Healthwatch Barnet is the independent consumer champion for people who use health and social care services in Barnet. It will ensure local people’s views are heard in order to improve the experience and outcomes for people who use them. You can tell Healthwatch what you think about Barnet’s health and social care services. Healthwatch can also give you advice and information about local health services. Health inequalities Health inequalities can be defined as unfair differences in health status or in the distribution of health determinants between different population groups. For example, differences in mortality rates between people from different social classes. In Barnet, there are big health inequalities that exist between people who live in the west of the borough and those who live in the north. General health and life expectancy is worse in the west than the north and these are priority issues for the Health and Wellbeing Board. Health and Wellbeing Board (HWBB) The Health and Social Care Act 2012 established Health and Wellbeing Boards as forums where leaders from the NHS and local government can work together to improve the health and wellbeing of their local population and reduce health inequalities. Barnet’s Health and Wellbeing Board includes elected members of Barnet Council, the Strategic Director of Adults, Communities and Health, Public Health, Children’s and Young People Services, members of Barnet CCG and a representative of Healthwatch Barnet. Board members work together to understand Barnet’s health and social care needs, agree priorities and help to ensure that the Council and the CCG plan and buy services in a more joined up way. The Board is responsible for carrying out the Joint Strategic Needs Assessment (JSNA) and developing a joint strategy (the Health and Wellbeing Strategy) for how these needs can be best addressed. Health and Wellbeing Strategy Barnet's Joint Health and Wellbeing Strategy 2015-2020 has been developed by our Health and Wellbeing Board (HWB). It is our overarching plan to improve the health and wellbeing of children and adults in our borough and to reduce health inequalities between the least

255255


deprived and most affluent areas in the borough. Our Health and Wellbeing Strategy sets out our vision for Barnet and is informed by our Joint Strategic Needs Assessment (JSNA). Joint Strategic Needs Assessment (JSNA) A JSNA describes the future health, care and wellbeing needs of local populations and the strategic direction of service delivery to meet those needs. JSNAs are developed jointly between the Council and the CCG – providing a framework for health and social care to work in partnership to identify the needs of the population they serve and to work together in commissioning services to meet those needs. The JSNA is a key part of the commissioning cycle and informs the CCG’s commissioning intentions. Key Performance Indicators (KPI) These are set out in contracts with our providers and help us to monitor their performance. Examples of KPIs include length of stay in hospital for a particular treatment or how satisfied patients are with the care they receive. Long term condition We define a long term condition as something that cannot be cured at the moment, but can be controlled by medication and/or other therapies, including self-care and changes to life-style. This definition covers lots of different conditions including diabetes, asthma, multiple sclerosis and Myalgic Encephalomyelitis (ME)( Note: ME is characterised by a range of neurological symptoms and signs, muscle pain with intense physical or mental exhaustion, relapses, and specific cognitive disabilities. NICE guidance NICE stands for National Institute for Health and Care Excellence. NICE sets standards for quality healthcare and produces guidance on medicines, treatments and procedures. Visit their website for more information: www.nice.org.uk Patient Participation Group (PPG) A PPG is a group of patients who are interested in health and healthcare issues and who want to get involved with and support the running of their local GP practice. Most Patient Participation Groups (PPGs) also include members of practice staff, and meet at regular intervals to decide ways and means of making a positive contribution to the services and facilities offered by the practice to its patients. All our GP practices are expected to have a PPG. Planned care

256256


Planned care means services where you have a pre-arranged appointment. This includes being referred by your GP to see a physiotherapist or consultant or being sent for diagnostic tests such as an X-Ray. Primary care Primary care is the services provided by GP practices, dental practices, community pharmacies and high street optometrists. Around 90 per cent of people's contact with the NHS is with these services. Most primary care services are commissioned by NHS England, not the CCG. Procurement The process of specifying and buying (or leasing) goods or services, evaluating bids, and negotiating contracts with providers. Providers/Service Providers We use the term provider or service provider to include anyone who is commissioned to supply a health or care-based service. For example, GPs are primary care providers. Social care providers include social workers and home support workers. Hospitals like University College London Hospital and Royal Free are also providers. Secondary care Secondary care is the services provided by medical specialists, quite often at a community health centre or a main hospital. These services are provided by specialists following a referral from a GP, for example, cardiologists, urologists and dermatologists. What is an STP? The Sustainability and Transformation Partnerships (STP) sets out how local health and care services will transform and become sustainable over the next five years, building and strengthening local relationships and ultimately delivering the Five Year Forward View vision

The North London PARTNERS in health and care are a partnership of health and care organisations from the five London boroughs of Barnet, Camden, Enfield, Haringey and Islington. It includes:

Barnet, Camden, Enfield, Haringey and Islington CCGs Barnet, Camden, Enfield, Haringey and Islington Councils Barnet, Enfield and Haringey Mental Health NHS Trust Camden and Islington NHS Foundation Trust Central and North West London NHS Foundation Trust Central London Community Healthcare NHS Trust Moorfields Eye Hospital NHS Foundation Trust

257257


North Middlesex University Hospital Royal Free London NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust The Tavistock and Portman NHS Foundation Trust University College London Hospitals NHS Foundation Trust Whittington Health NHS Trust

More information can be found on: http://www.northlondonpartners.org.uk/

Social Prescribing

Social prescribing involves helping patients to improve their health, wellbeing and social welfare by connecting them to community services which might be run by the council or a local charity. For example, signposting people who have been diagnosed with dementia to local dementia support groups. It provides GPs with a non-medical referral option that can operate alongside existing treatments to improve health and wellbeing.

Extended Access

The service is provided through various practices in Barnet, with 48,000 additional appointments a year to its residence, 7 days a week (including all bank holidays). Any Barnet registered patient can book an appointment to see a local GP or nurse, who offer the same care at hub locations as your usual GP. Just phone or visit your usual GP and ask about the Extended Access appointments or call our call centre between 6.30pm and 9pm weekdays and 8am – 8pm weekends 020 3948 6809.

Integrated Care Systems

In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.

Local services can provide better and more joined-up care for patients when different organisations work together in this way. For staff, improved collaboration can help to make it easier to work with colleagues from other organisations. And systems can better understand data about local people’s health, allowing them to provide care that is tailored to individual needs.

Barnet Federated GPs

Barnet Federated GPs CIC is an organisation consisting of 54 general practices in the London Borough of Barnet covering approximately 400,000 patients. A GP federation is a group of general practice surgeries and practices coming together to form an organisation which can provide high quality services to the local area. Practices remain independent but collaborate and share resources to improve day-to-day functioning and patient care. The company was first formed in November 2015 through the coming together of GP surgeries in all 3 localities within Barnet (North, South and West).

258258

Documents

AGENDA - Barnet CCG · Single CCG Helen Pettersen Simon Goodwin Ian Porter Approve 69 10:00 ... fair and transparent and offer value for money. Conflicts of interest guidance to which