Minutes of the Meeting of the Haringey Clinical Commissioning Group Governing Body

Wednesday 30 November 2016 at 1.30pm Cypriot Centre, Earlham Grove

Present:

Dr Peter Christian PC Chair of Haringey CCG, West Lead

Sarah Price SP Chief Officer, Haringey CCG

Dr Muhammed Akunjee MA GP Governing Body Member, South East Lead

Dr Gino Amato GA GP Governing Body Member, North East

Dr Simon Caplan SC GP Governing Body Member, North East

Dr Jeanelle De Gruchy JDG Director of Public Health, Haringey Council

Catherine Herman CH Lay Member and Vice Chair, Haringey CCG

David Maloney DM Chief Finance Officer, Haringey CCG

Dr David Masters DMa GP Governing Body Member, West

Dr Sheena Patel SPa GP Governing Body Member, Central Lead

Dr John Rohan JR GP Governing Body Member, North East Lead

Sharon Seber SS South East Primary Care Health Professional Member, Haringey CCG

Adam Sharples AS Lay Member, Haringey CCG

Dr Dai Tan DT Salaried/Sessional GP Governing Body Member

Sarah Timms STi Nurse Member, Haringey CCG

In attendance:

Rachel Lissauer RL Director of Commissioning

Jill Shattock JS Director of Performance

Jennie Williams JW Executive Nurse and Director of Quality and Integrated Governance

Sharon Grant SG Chair, Heathwatch Haringey (Observer with speaking rights)

Will Maimaris WM Consultant in Public Health, Haringey Council

Steve Beeho SB Head of Integrated Governance, Haringey CCG (minutes)

1. INTRODUCTION Action

1.1 Apologies for Absence

1.1.1 Apologies were received from Dr Dina Dhorajiwala.

1.2 Declarations of Interest

1.2.1 No additional declarations were received.

1.3 Chair’s Introduction and Opening Remarks

1.3.1 The Chair formally welcomed all present to the meeting.

1.4 Minutes of the Previous Meeting

1.4.1 The Governing Body APPROVED the minutes of the meeting held on 29 September 2016 as an accurate record.

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1.5 Matters Arising

1.5.1 A number of verbal updates to the action log were provided.

1.5.2 Adam Sharples highlighted with regards to the update to action 29.9.16/3 that NHS England do not have information relating to the number of appointments provided by GP practices in hours, which means that the CCG is unable to determine whether the opening of the hubs had had an impact on the number of appointments offered by practices under their core contract. While this is ultimately a matter for NHS England at present, if the CCG moves to ‘level 3’ commissioning of primary care the lack of this level of information would adversely affect the CCG’s ability to monitor the impact of local investment in primary care, so he hoped that the position would change in future.

1.5.3 Peter Christian noted that recording the number of face to face appointments is only one measure of patient access and the growth in the number of telephone consultations and advice provided by other members of practice teams is also having a positive impact which cannot easily be quantified.

1.5.4 Sharon Grant acknowledged this but she encouraged the CCG to keep track of the number of physical appointments, in order to continue to build on the previous study of GP access which Healthwatch had undertaken.

1.5.5 Jennie Williams advised regarding action 29.9.16/4 that Kim Holt had recently been appointed as the Designated Doctor for Safeguarding and would be providing an update on the increase in the percentage of looked-after children placed more than 20 miles outside the borough to a future children’s safeguarding assurance meeting.

1.5.6 Sarah Timms requested more information about the impact in Newham of having a named midwife in children’s centres as the update for action 29.9.16/6 did not adequately address this.

1.5.7 It was agreed that the breakdown of the proportion of NMUH patients seen under the 2 week wait target who are diagnosed with cancer (action 29.9.16/10) would be circulated to Sharon Grant outside the meeting.

1.5.8 Jill Shattock noted that the report on the improved performance at the NMUH A&E department would be brought to the Governing Body in May 2017, rather than March, following the completion of the Safer, Faster, Better work.

1.5.9 Rachel Lissauer provided a verbal update on the provision of dementia services in Haringey in response to a query from a member of the public.

1.5.10 The Governing Body NOTED the action log.

1.5.11 ACTION 30/11-1: To arrange for Susan Otiti to provide further information about the impact in Newham of having a named midwife in children’s centres.

SB

1.5.13 ACTION 30/11-2: To forward to Sharon Grant the breakdown of the proportion of NMUH patients seen under the 2 week wait target who are diagnosed with cancer.

SB

1.6 Questions From the Public

1.6.1 No questions had been received.

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2. Overview Reports

2.1 Chief Officer’s Report

2.1.1 Sarah Price highlighted a number of items in the Chief Officer’s Report.

2.1.2 She welcomed the recent official opening of a new GP practice at Tottenham Hale and the CCG’s provisional award of funding for three new purpose-built GP practice buildings through NHS England’s Estates and Technology Transformation Fund. A project manager has been recruited to support the CCG through the next stage of the process.

2.1.3 The North Central London (NCL) maternity network, which brings together commissioners, providers and users of maternity services, has been chosen by NHS England to become an early adopter for the National Maternity Review, Better Births. Work will begin in December 2016 to align the successful bid with the Sustainability and Transformation Plan (STP).

2.1.4 Haringey CCG’s Chair Dr Peter Christian had sat on a panel of experts at the recent Voluntary and Community Sector Expo. The event, which was organised by the Bridge Renewal Trust in partnership with Haringey Council, was the first of its kind in the borough and was well-attended.

2.1.5 The Governing Body then discussed the report. Sharon Grant asked for clarification regarding the location of “the Iceland building” referred to in the report as one of the proposed locations for the new practice buildings and also queried the rationale for the proposed locations, given that they appeared to be located relatively close together, despite the greatest need being in the east of the borough.

2.1.6 Sarah Price confirmed that one of the proposed locations is the site of the current Iceland store behind Wood Green Shopping City. She also explained that a needs assessment carried out earlier in the year had identified the area around Wood Green High Rd as a high-need area, particularly on account of the large number of small practices which had closed or are due to close. The actual buildings had been chosen in collaboration with Haringey Council, based on the available opportunities and the Council’s regeneration plans.

2.1.7 Catherine Herman highlighted that the proposed locations are also partially based on predicted population growth. She welcomed the fact the Haringey bids had been so well-received, which was a testament to the quality of the submissions and the joint working between the CCG and the Council.

2.1.8 Jeanelle De Gruchy echoed this and noted that more detail would be provided in due course to the Health and Wellbeing Board.

2.1.9 The Governing Body NOTED the Chief Officer’s Report.

3. DISCUSSION

3.1 Improving Health Outcomes for Children and Young People

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3.1.1 Will Maimaris provided an overview of the presentation on current population health information on stroke in Haringey, and the approach being taken across agencies to improve health outcomes relating to stroke. The presentation highlighted the current mortality rate, as well as the high rates of hospital admissions and high acute spend resulting from stroke. Stroke mortality has a significant impact on health inequalities in the borough, with Bangladeshi people 1.9 times more likely to be diagnosed with stroke/transient ischaemic attack (TIA) compared to the Haringey average, and Mixed White and Black Caribbean people 1.6 times more likely.

3.1.2 As 80% of strokes are considered preventable, achieving similar rates of diagnosis and control as those achieved in Newham and Canada, where significant improvement had been achieved, would make a considerable impact. The presentation outlined the population-based approach being taken in Haringey, with a range of preventive initiatives in place to identify and manage people at risk of stroke, while also making it easier for people to make healthy choices, as well as a number of post-stroke initiatives to support the management of stroke and TIA and to maximise people’s independence.

3.1.3 Stroke prevention initiatives in primary care have increased the diagnosis of atrial fibrillation (AF) and Hypertension. More new cases have been identified over the past year in Haringey than in any other London borough.

3.1.4 A review of the stroke pathway has been carried out at North Central London-level in order to reduce the length of stays and improve outcomes. The development of a lead provider for the acute stroke care pathway will form a key part of this. The recently completed commissioning of the post-stroke support service by Haringey CCG and Haringey Council will also provide good opportunities to link up with primary care to reduce the likelihood of people having further strokes following mini-strokes.

3.1.5 In conclusion, Will Maimaris welcomed the Governing Body’s views on

How to ensure the continued prioritisation of improved AF and hypertension

identification and management

The emerging proposals to commission a lead provider for the acute stroke care

pathway across NCL

How to improve communication and liaison between the Stroke Recovery

Service and GPs to ensure that stroke survivors can access the service and that

the outcomes of the 6-months reviews are followed up.

3.1.6 The Governing Body then discussed the issues raised by the presentation. Peter Christian queried whether the recent deterioration in performance in stroke patients being seen within the two hour ‘window’ has been caused by delays in ambulance transfers. Sarah Price confirmed that this is a partial cause but ‘bed-blocking’ is also a significant factor.

3.1.7 Catherine Herman queried whether AF is routinely checked under primary care. She also welcomed the look of the new Stroke Recovery Service and was optimistic that it will improve patients’ post-stroke quality of life.

3.1.8 Gino Amato commented that he would support the training of all staff, clinical and even non-clinical, to promote pulse checking and blood pressure checking, to aid in the detection of AF and poorly-controlled or un-diagnosed hypertension. To do this, however, would take a commitment to fund the work across an extended period of years, rather than approving stroke prevention programmes from year to year.

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3.1.9 Sharon Seber suggested that it would be helpful to include data on pulse-check rates on practice dashboards so that they can benchmark themselves. She also highlighted that discussions are taking place within the Healthy Life Expectancy Group about a potential communications programme across primary and secondary care, possibly in association with the Stroke Association for ‘Purple May’.

3.1.10 Dai Tan observed that diagnosing AF can be difficult unless patients are already in the system and a more streamlined approach is needed. At present patients go back and forth between the GP and hospital before the final diagnosis is made, when it would be easier to have one place where patients can go to, get all the tests done, and diagnosis can also be made for AF.

3.1.11 Jeanelle De Gruchy highlighted that Haringey has the worst figures for premature strokes in London and concerted effort is required to turn things around.

3.1.12 John Rohan agreed that a more aggressive approach is needed and rather than targeting the 45+ age group, resources would be better directed at even younger patients, potentially aged 30 and onwards. He acknowledged that this approach might ultimately necessitate long-term commitments from patients to self-manage their conditions.

3.1.13 Catherine Herman echoed the challenge posed by Jeanelle De Gruchy and recommended learning from progress that is being made in other areas.

3.1.14 Adam Sharples observed that the breakdown in the presentation demonstrated a particular concentration by both geography and ethnic group, and it would therefore be sensible for agencies to prioritise accordingly.

3.1.15 Sharon Seber agreed, and noted that evidence suggests there is also an overlap with smoking and illicit drug use in relation to people having strokes at young ages.

3.1.16 Simon Caplan backed John Rohan’s suggestion for reducing the age of the target group and questioned whether it might even need to be reduced further, to start with 25 year-olds and above. Health Trainers could play a key part in targeting these groups.

3.1.17 Sharon Grant observed that Healthwatch would be keen to play an active part if there was an appetite to use the voluntary sector to communicate messages to the public.

3.1.18 Sharon Seber advised that she has had preliminary discussions with the YMCA Hornsey as they have undertaken health checks (including blood pressure) for local business in other areas. This may be of interest when thinking of some of the harder to reach patient groups.

3.1.19 Summing up, Sarah Price agreed on the importance of stronger communications and assured the Governing Body that this would be taken forward. It was also important for the NCL pathway to be streamlined and work on this is progressing well. Making it easier for patients to monitor their blood pressure also has a key part to play. The proposed move towards the CCG assuming level 3 responsibility for commissioning primary care will also allow it to exert more control over local initiatives.

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3.1.20 Catherine Herman commented that as Haringey is an outlier in both NCL and London it will need to place strong pressure on this to deliver improvements. The Islington population exhibits a similar risk factor but has benefited from greater investment over time.

3.1.21 Peter Christian observed that the key challenge is to communicate the prevention message about a condition which people cannot see or feel.

3.1.22 John Rohan suggested that the one-off cost of investing in blood pressure machines for practice waiting rooms would pay dividends in the longer term. He acknowledged that the volume of people who eventually stop following treatment remains a challenge but this could be mitigated by surgeries pro-actively contacting patients who have not been seen for a long time. Peter Christian observed that in-house practice pharmacists can also have a significant impact in this area. Jeanelle De Gruchy said that engaging with Patient Participation Groups would also be beneficial.

3.1.23 In response to a query from Lionel Sherman, Will Maimaris explained that the improvements recorded in Canada largely stem from an increased focus on prevention through primary care. As part of this all GPs carry out an annual hyper-tension audit, with a strong emphasis on self-testing.

3.1.24 Sharon Grant queried whether there was any variation in the stroke rate for men and women. Will Maimaris confirmed that the rate was higher among young men than young women, but the rate evens out over time. This could be confirmed by providing a breakdown of stroke rates by gender outside the meeting.

3.1.25 ACTION 30/11-3: To circulate outside the meeting a breakdown of stroke rates by gender.

WM

4. Strategy and Development

4.1 Integrated Out of Hospital Services

4.1.1 Rachel Lissauer provided an overview of the progress being made on discharging patients from hospital in order to reduce length of stay and improve outcomes. This was being addressed via two programmes: improving ‘Out of Hospital’ services as part of the Safer Faster Better Programme which is improving urgent and emergency care at North Middlesex University Hospital, and developing a joint approach towards integration of out of hospital services with Haringey Council.

4.1.2 She highlighted in particular how undertaking assessments of patients’ long term health and social care needs once they have been discharged out of hospital through the ‘Out of Hospital’ services programme has already resulted in one to three days delay being avoided for up to five patients per week. Reducing unnecessary paperwork for continuing healthcare assessments has also streamlined the process from 15 to 10 days and reduced delays.

4.1.3 Sharon Grant queried whether the impact of these changes was being evaluated from the patients’ perspective. Feedback from patients has revealed that some people feel that they are being discharged with undue haste, which can create anxiety.

4.1.4 Rachel Lissauer commented that this can be difficult to evaluate as people do not necessarily know how they might have otherwise been treated. She would investigate, however, whether patients’ views of their treatment are measured.

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4.1.5 Sarah Price agreed that active reablement should be the main focus, by putting things in place to help this to happen. The presumption is to return people to where they feel they belong and if that does not work, or further support is required, then this will be picked up.

4.1.6 Catherine Herman welcomed these programmes as precisely the sort of transformational work which the CCG ought to be taking forward. However, she acknowledged that the issue of post-discharge support needs more attention. The potential involvement of the community and voluntary sector in the rapid response initiative was also welcomed.

4.1.7 Jennie Williams observed that there is still work to be done in local trusts to ensure that important discussions take place with patients at the beginning of their package of care. In relation to NMUH, this work is being led by the Director of Nursing.

4.1.8 Gino Amato cautioned that a system is only as good as its final part and social care services are already under heavy pressure.

4.1.9 Jeanelle De Gruchy agreed that this is a challenge but the ultimate goal should still be to get people back home where possible. Responding to Jennie Williams’s earlier comment, she highlighted the need to ensure that hospitals have the expertise in place to distinguish between those patients who should be discharged home and those who require a package of care.

4.1.10 The Governing Body NOTED the progress with plans to improve the process of discharging patients from hospital to reduce length of stay as part of the Integrated Out of Hospital Programme.

4.1.11 ACTION 30/11-4: To confirm to the Governing Body whether the views of patients treated under the ‘Out of Hospital’ programme are recorded.

RL

4.2 London Health Care and Devolution

4.2.1 Sarah Price provided an overview of the progress being made in the five London ‘devolution’ projects established under the London Health and Care Devolution Programme. These pilots, which are designed to facilitate better outcomes by devolving decision-making on behalf of local populations, focus on three priorities: prevention, health and social care integration and better use of health and care buildings and land.

4.2.2 The CCG is participating in two pilots – a prevention pilot in Haringey and an NCL-wide estates pilot.

4.2.3 Jeanelle De Gruchy explained that as the prevention pilot has evolved it has been decided to focus on licensing proposals relating to alcohol and tobacco and supporting people with mental health conditions back who are on sickness absence so that they remain in employment. The business cases were submitted in November, with final agreement anticipated in January 2017. Developing the licensing proposals has proved challenging as these hinge on what legal powers can be exercised locally.

4.2.4 In response to a question from Simon Caplan, Sarah Price confirmed that the election of a new Mayor of London has not had a material impact on the programme.

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4.2.5 Adam Sharples noted that he had attended a number of meetings as a member of the Mental Health/Employment committee but despite the large number of good ideas produced, the lack of actual progress made was disappointing. In reality many of the actions that need to be taken require joint working, rather than actual devolution, and therefore he hoped that the CCG will avoid this experience being replicated going forward.

4.2.6 Jeanelle De Gruchy echoed this frustration but noted that capacity issues have also impeded progress at times. She would see what could be done to address this.

4.2.7 Sharon Grant queried whether the estates strategy takes account of the place-based focus of the delivery of health and social care or is essentially a vehicle for generating capital receipts for the NHS. She cautioned against prematurely disposing of buildings which may be needed in future. Although there is a lot of talk about increasing the involvement of the voluntary sector but at the same time the number of suitable premises is steadily decreasing.

4.2.8 Sarah Price confirmed that the estates strategy is considering the issue in its totality. From a local point of view there was a strong desire to identify premises which can bring services together in the form of community ‘hubs’. She clarified to Sharon Grant that when a practice closes in many cases the NHS does not actually own the building, so the disposal of the premises is purely a matter for the practice. This work is focusing more on the high percentage of the NHS estate which is not being used and is often in poor condition.

4.2.9 David Maloney highlighted the importance to the local health economy of being able to reinvest the money raised by the planned disposals at St Anne’s, St Pancras and Moorfields Hospitals.

4.2.10 Sharon Grant observed that it is nevertheless important to question whether any planned disposals will contribute to the objectives of improving health and wellbeing.

4.2.11 David Maloney emphasised that the key purpose of the estates devolution is to ensure that capital receipts are retained in London, rather than dispersed to the wider system. All developments are subject to the approval of business cases and a consultation process as appropriate.

4.2.12 The Governing Body NOTED the progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015, SUPPORTED the development of the final Devolution agreement(s) and DELEGATED authority to the CCG Chair, Peter Christian, to APPROVE and sign off the agreement on behalf of the CCG.

4.3 Haringey and Islington Wellbeing Partnership

4.3.1 Rachel Lissauer provided an update on the work being undertaken jointly across health and social care in Haringey and Islington through the Haringey and Islington Wellbeing Partnership, including the proposal to develop an Accountable Care Partnership (ACP).

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4.3.2 This proposal had been developed as part of the response to the STP, in recognition of the fact that Haringey and Islington already have a shared vision of a more integrated model of care. The proposed ACP would bring together commissioners and providers to work collaboratively and take responsibility for the cost and quality of care for a defined population within an agreed budget. Further work is being undertaken on what this might mean for ways of working, aims and objectives, governance and organisational forms and the pace of change. An update paper will be taken to the Health and Wellbeing Board in January 2017, prior to the statutory bodies being asked for their agreement after April 2017.

4.3.3 David Masters queried how the ACP would ensure that vulnerable patients in the east Haringey are not overlooked in the development of this new model.

4.3.4 Rachel Lissauer confirmed that UCLH and NMUH are both actively involved in the developmental work.

4.3.5 Simon Caplan asked whether there were any positive examples of ACPs which could be cited. He also questioned whether there had been any patient and public involvement to date.

4.3.6 Rachel Lissauer explained that there are a range of ways of bringing organisations together. Vanguard partnerships have either set up a Trust which manages support services by becoming a lead provider or a federation of practices which manages the health needs of the population, with a network of clinicians and other professionals, while also involving the voluntary sector. This is closer to the intended model. That said, there is no inevitability that the model will deliver better outcomes. In order to be successful it requires strong clinical leadership, good use of analytical tools, pro-active case management, an effective preventative approach and good information-sharing.

4.3.7 As the concept of the ACP is still being worked through there had not been any specific local engagement, although there had been a good discussion about the principle at the last meeting of the Patients Network.

4.3.8 Sarah Timms queried what the difference is between an ACP and an Accountable Care Organisation (ACO).

4.3.9 Rachel Lissauer noted that the approach to contracting has moved on locally and nationally. Under an ACO there would be loose contractual arrangements which would be more binding than a Memorandum of Understanding and does not rely on a lead provider, as before. The ACP vanguards are looking at the creation of more formal joint organisations, but this option is not being considered in Haringey and Islington. The priority instead is to develop a structure which supports delivery on the ground.

4.3.10 Sarah Price observed that what is being proposed represents a step on from Value Based Commissioning (which focused on cohorts of patients) to a ‘whole population’ approach.

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4.3.11 Adam Sharples said that he had previously been sceptical about the merits of creating an ACP and the paper had not changed this. While he was in favour of working more closely with Islington, he was not clear how the creation of an ACP would relate to the other new structures which are being proposed under the STP, including the establishment of a Joint Committee. If there is an argument for removing the boundary between commissioners and providers, this would be best considered at NCL level first, before being considered locally. He hoped therefore that this discussion would not be construed as giving the green light to the final decision.

4.3.12 Sarah Price commented that it is important to recognise that the STP is a plan, rather than an organisation, and the plan will be delivered at a local level, rather than NCL level. It is envisaged that the creation of an ACP would support the delivery of the STP by bringing together partner organisations to work more effectively across the piece, rather than just focusing on acute trusts, and thereby drive forward at the local level what needs to happen.

4.3.13 Catherine Herman observed that the underlying rationale for the STP is to blur the distinction between commissioners and providers and the best way of encouraging people to work together is to create a shared commonality of vision, so it makes sense to develop in directions where goodwill already exists and there is a strong prospect of strategic alignment. Focusing on organisations alone will not in itself provide a model for progress.

4.3.14 Jill Shattock observed that the development of an ACP will also strengthen opportunities for improving community services by virtue of bringing Whittington Health to the table in a more constructive environment.

4.3.15 Sharon Grant observed that it had proved difficult to explain the proposed changes at a recent Healthwatch Haringey Consultative Group meeting, particularly what was meant precisely by the word ‘accountability’.

4.3.16 Rachel Lissauer confirmed that in this context it was being used in terms of being accountable for the budget, rather than in a strict governance sense.

4.3.17 Catherine Herman agreed that there is a communications issue which needs to be addressed, focusing in particular on the individual strands of work and specific changes.

4.3.18 In response to a question from Simon Caplan about clinical involvement, Rachel Lissauer noted that engagement sessions have taken place at different stages, including one in advance of the recent STP ‘lock-in’, as well as communications around individual workstreams.

4.3.19 The Governing Body NOTED the plan which had been endorsed by the Joint Haringey and Islington Wellbeing Board.

4.4 North Central London Sustainability and Transformation Plan (STP)

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4.4.1 Sarah Price noted that the NCL STP had been submitted to NHS England on 21 October 2016. Subsequent feedback indicated that further work will be required on this, particularly in respect of identifying additional financial savings, although no deadline has been set. A number of Councils had chosen to publish the draft document during the embargo period. The CCG had discussed the STP with various groups, including 38 Degrees and its engagement network, as well as at public meetings. The CCG will continue to maintain a dialogue with interested parties, although it was acknowledged that some of the detail still remains relatively nebulous at this stage.

4.4.2 In response to a query from Adam Sharples about the further financial savings required, David Maloney commented that there is an expectation from NHS England that CCGs will achieve the overall NCL control total for 2017/18 and at present the plan contains a large financial gap. He also highlighted the requirement for the 2017/18 and 2018/19 contracting rounds to be completed within the next three weeks. Achieving this will be challenging for all parties. The size of the financial gap identified in NCL was comparable with other patches across London.

4.4.3 Sharon Grant observed the Healthwatch Haringey Consultative Group had issued a statement expressing concern about the lack of engagement about what is being proposed, as this did not augur well for the future.

4.4.4 Sarah Price assured the Governing Body that the CCG is committed to engaging over the plan as much as it can, but as the plan does not talk about how it will be delivered, the CCG is unable to discuss the details at present. The hardest aspect of the STP will be holding all the parties together while delivering long-term solutions.

4.4.5 David Masters highlighted the potential risk of managing the process in the context of what might be severe management upheaval.

4.4.6 Sarah Price commented that the scale of the challenge requires radical action, and therefore partnership working is crucial. Going forward it will be imperative to preserve the principle of clinical decision-making, while at the same time extending it across a range of clinicians and organisations.

4.4.7 Simon Caplan also relayed the LMC’s concern about the need to ensure under the STP that there is clinical involvement in key decisions such as changing pathways, rather than there being a top-down approach from managers.

4.4.8 The Governing Body NOTED the North Central London Sustainability and Transformation Plan and SUPPORTED the direction of travel and priorities for improving services and outcomes set out in the STP.

4.5 Development of CCG Commissioning Arrangements in North Central London

4.5.1 Sarah Price provided an overview of the paper setting out the proposed new commissioning arrangements in North Central London, including the proposal to establish a Joint Committee of North Central London CCGs and proposed management arrangements. The Governing Body then discussed the paper.

4.5.2 Sarah Timms highlighted the importance of ensuring that there is a senior quality lead post among the new central NCL team to be consistent with the fact that acute commissioning will be driven at this level. The lack of such a post would also make it difficult for the local CCG quality leads to link in to the over-arching management team.

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4.5.3 Sarah Price suggested that this responsibility could potentially be added to the Director of Performance position.

4.5.4 Sarah Timms said that this would be acceptable in principle, subject to assurances about the role’s remit and responsibilities.

4.5.5 Sarah Timms also expressed concern about the lack of a clinical majority on the Joint Committee, given how integral this principle was to CCGs when they were first established, and she was keen to maintain this. She therefore proposed that the Joint Committee should include a third clinical advisor, who would be a nurse.

4.5.6 Adam Sharples observed that lead responsibility for equality of provision was also not explicitly assigned in any of the documents and he sought assurance that this would be addressed. He also noted that with the move to a Joint Committee there should also be discussion about which CCG committees might also warrant consolidation as a single NCL committee, the Audit Committee being a prime example.

4.5.7 David Maloney noted that the CCG had raised the idea of having a third clinical representative following the seminar discussion but had received assurances that the voting arrangements would ensure that a clinical majority would always be required.

4.5.8 Although Sarah Timms accepted this, she nevertheless still believed that there should be at least one nurse member on the Joint Committee to reflect the range of clinical expertise.

4.5.9 Catherine Herman observed that it is important to strike the appropriate balance between what is done locally and what is done at NCL level. She therefore questioned whether the proposed Joint Committee should meet monthly, when the CCG Governing Bodies meet on a bi-monthly basis.

4.5.10 David Masters suggested that the proposed changes might adversely affect the level of future clinical engagement and therefore make it more difficult for CCGs to recruit clinicians.

4.5.11 Sarah Price observed that the paper reflected the direction of travel, and therefore funding the central team will require some local resource being redirected. It was hoped that increasing joint working between Haringey and Islington CCGs will enable the two organisations to maintain more senior leadership.

4.5.12 Peter Christian commented that the dynamics of the relationship between the two CCGs will be particularly important. There was a mutual recognition that both CCGs share a lot in common and there is already a good existing relationship, so there is a strong basis to build on, although there will inevitably be some reservations.

4.5.13 Sarah Price agreed and highlighted as an example that the respective Social Care departments are already beginning to work in a cross-boundary fashion.

4.5.14 David Masters questioned whether member practices need to be engaged on the proposed changes. Simon Caplan suggested that assurance should be sought from the LMC on whether the CCG would need to obtain members’ approval, if it is deemed to affect members’ rights, liabilities or duties. Gino Amato said that the changes would not affect members’ positions.

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4.5.15 The Governing Body APPROVED the following as set out in paper 2:

The delegation of responsibility for the commissioning of the following services to an NCL joint committee:

o Acute services including core contracts and other out of sector acute commissioning;

o All learning disability contracting associated with the Transforming Care Programme;

o All integrated urgent care (including NHS 111/ GP Out-of-Hours services); and o Any specialised services not commissioned by NHS England.

That the proposed shared NCL committee will take the form of a joint committee

That the membership of the proposed joint committee be as outlined in section

4 of paper 2

The delegation of responsibility for the application of their resources for the

commissioning of the delegated areas (acute commissioning, Transforming

Care, integrated urgent care and specialised services) to an NCL joint

committee

That the shared Chief Finance Officer (CFO) post represents each of the five

CCGs, and has the accountability for financial management of the resources to

support the acute services commissioned, and equally has accountability to

each CCG in line with statutory requirements for the areas delegated.

That the shared CFO develops the financial strategy into a set of policies and

procedures, which will require endorsement by the joint committee for

operation

That the shared CFO represents the five CCGs in finance and performance

monitoring meetings with NHS England

The Terms of Reference and Standing Orders for the joint committee as set

out as Appendices 2 and 3 of paper 2

The appointment of the independent joint committee members

The process assurance of the performance and quality of the proposed Joint

Committee as outlined in section 8 of paper 2

The process for assurance of the financial management of the proposed Joint

Committee as outlined in section 8 of paper 2

That the Joint Committee complete an annual self-assessment of performance

and develop an action plan to address any issues that arise

A three-part escalation process that may be implemented if the joint committee

is perceived to be unsuccessful as set out in section 8 paper 2

Amendments to the Scheme of Reservation and Delegation as set out in

section 10 of paper 2.

The Governing Body also APPROVED the following as set out in paper 3:

The creation of a new Local Executive Director role [this title may change], to lead the delivery of local functions, alongside the shared director roles

The proposal for a shared Director of Strategy and a shared Director of Performance and Acute Commissioning

That all CCG running cost workforce in finance, performance and acute commissioning functions be line managed by the new shared Local Executive Director roles

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That the management of the core CSU support contracts be reviewed across the five CCGs based on their needs and reflecting the proposals of the new commissioning arrangements.

That accountability for the management of the core CSU support contracts be delegated to the new shared Accountable Officer, who would have responsibility for signing the core contracts on behalf of the five CCGs

That the day-to-day management of the CSU support resource where is relates to acute contracting, be undertaken by the proposed Director of Performance and Acute Commissioning

That Islington CCG act as the host employer for any new appointments that are shared across the NCL CCGs.

4.5.16 This approval was subject to further clarification/confirmation being obtained regarding the following points which had been raised in the earlier discussion:

The frequency of Joint Committee meetings

The membership of the Joint Committee and in particular whether there should

be a Nurse Member

How will the complaints system operate under the new arrangements

Assurance on where responsibility for equality of provision will be assigned

Legal advice to be sought on whether the agreement of the membership needs

to be obtained for what is being proposed.

4.5.17 Sarah Timms requested that her belief that the Joint Committee should include a Nurse Member should be recorded in the minutes of the meeting.

4.5.18 Adam Sharples supported Sarah Timms’ comment but like her, did not consider that this was sufficient reason in itself to withhold support. He was therefore also willing to approve the above, subject to legal advice.

4.5.19 Sarah Price then highlighted that further Remuneration Committee meetings are scheduled for 7 December 2016 and in early January 2017. As these meetings would be taking place before the next Governing Body meeting in February 2017, the Governing Body was asked to agree to delegate decision-making power to the Remuneration Committee for both meetings.

4.5.20 The Governing Body AGREED to delegate decision-making power to the Remuneration Committee at the planned meetings on 7 December 2016 and early January 2017.

4.6 Primary Care Co-Commissioning

4.6.1 Sarah Price provided an overview of the paper seeking Governing Body approval for the CCG to submit an expression of interest to become Primary Care delegated commissioners, along with Barnet, Camden and Enfield CCGs. The paper set out the preparatory programme of work which has taken place, the context in which the proposed move to becoming a delegated commissioner of Primary Care was being made and how it will help to address local needs. It also set out identified opportunities and risks, and detailed the functions which would become the responsibility of the CCG and those which would be retained by NHS England.

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4.6.2 The proposed expression of interest was subject to due diligence work and a finalised governance arrangement which would allow the four delegated CCGs (Enfield, Haringey, Barnet and Islington) to meet as Committees-in-Common, alongside one Joint Co-Commissioning CCG (Camden).

4.6.3 The Governing Body then discussed the paper. In response to a query from David Masters, Sarah Price confirmed that performance management of practices will remain the responsibility of NHS England. This had also been covered in the earlier Questions and Answers document and via face to face briefings with members. She also confirmed to Gino Amato that the inheritance of QIPP efficiency savings targets is a national requirement.

4.6.4 Adam Sharples noted that he and Sarah Price, in their respective capacities as Audit Committee Chair and Accountable Officer, were ultimately required to sign the application and “hereby confirm that Haringey CCG membership and Governing Body have seen and agreed to all proposed arrangements in support of taking on delegated commissioning arrangements for primary medical services on behalf of NHS England for 2017/18”. He confirmed that he was happy to support what was being proposed.

4.6.5 Sharon Grant highlighted that there is an expectation under section 5.2 that Healthwatch will have a role to play in mitigating conflicts of interest, and this would potentially have resource implications. Sarah Price clarified that this section was specifically referring to the involvement of Healthwatch in the NCL Primary Care Commissioning Committee.

4.6.6 The Governing Body APPROVED the recommendation that Barnet, Haringey, Islington and Enfield CCGs submit an expression of interest to become Primary Care delegated commissioners, subject to satisfactory conclusion of due diligence activities in the take on of delegated commissioning responsibilities and a finalised governance arrangement which allows four delegated CCGs (Enfield, Haringey, Barnet and Islington) to meet as Committees-in-Common, alongside one Joint Co-Commissioning CCG (Camden).

5. Business, Quality and Integrated Performance

5.1 Finance Report

5.1.1 David Maloney provided an overview of the CCG’s financial position at month seven. The report had previously been shared with the Finance and Performance Committee.

5.1.2 The CCG was continuing to forecast a break-even position at year-end. The reported run-rate was broadly in line with the previous month, which was encouraging.

5.1.3 The level of net risk facing the CCG in 2016/17 is approximately £3.2m, which primarily relates to the CCG losing access to its 1% reserve. An NCL-wide funding solution has been developed in order to provide financial coverage for cost pressures and to enable the delivery of CCG control totals.

5.1.4 David Masters commented that if the significant pressure on acute performance makes it even more important that the practice dashboards show clearly where there is over-performance.

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5.1.5 David Maloney confirmed that work is underway between the finance team and the primary care team to make the content more accessible. It was agreed that Cassie Williams would present a ‘clearer’ version of the practice dashboard at a future QIPP Delivery Group meeting.

5.1.6 The Governing Body NOTED the financial position at month 7.

5.1.7 ACTION 30/11-5: Cassie Williams to present a ‘clearer’ version of the practice dashboard at a future QIPP Delivery Group meeting.

CW

5.2 Performance and Quality Summary Report

5.2.1 Jill Shattock provided an overview of the Performance and Quality Summary Report, which included an in-depth appendix on mental health, summarising the current local situation and also looking forward for the next few years.

5.2.2 The main body of the report had been also been refined, to provide a greater focus on quality.

5.2.3 Jill Shattock highlighted a number of key points in the report. A&E performance at NMUH is continuing to improve and it also looked as if the trust would be compliant with the 62 day cancer target at the end of November. The CCG-wide diagnostic wait standard was not achieved in August 2016 but the provisional September 2016 data showed an improving trajectory. Unfortunately there was likely to be another dip in performance in October.

5.2.4 The Finance and Performance Committee had had a detailed discussion regarding concerns about Whittington Health Community Services and a plan of action had been agreed.

5.2.5 Feedback was also provided about the meeting that Simon Caplan, Adam Sharples and Jill Shattock had had with the London Ambulance Service (LAS). Following this the Trust Board had acknowledged that the issue in Haringey and Barnet regarding ‘red’ ambulances is partially caused by the fact that the lack of hospitals located in Haringey means that while ambulances may ‘start’ in Haringey, as their shifts progress they are sent to calls which tend emanate from closer to where patients are dropped off. The Trust will provide a report on how it will address this.

5.2.6 Adam Sharples noted that the Trust had also agreed to present to the Governing Body a report in six months’ time demonstrating progress against their action plan. He also highlighted that the Audit Committee had recently received a report from the internal auditors on Community Services which cautioned that “Ongoing performance issues may result in both patient harm and cause reputational damage to the Provider and CCG”.

5.2.7 Jill Shattock outlined to Catherine Herman the steps that the CCG had taken to date to try to improve Community Services’ performance. Unfortunately the ‘block’ contract has reinforced the opaqueness of the situation and to date there has been little progress on the promised dis-aggregation.

5.2.8 Catherine Herman suggested that this issue ought to be discussed by the Haringey and Islington Governing Bodies and then escalated via a letter signed by the Chairs and Chief Officers.

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5.2.9 Gino Amato agreed that it was vital for this issue to be escalated. He also observed that the mental health metrics do not tally with his experience as a clinician.

5.2.10 Jennie Williams confirmed that complaints are reported at Clinical Quality Review Group (CQRG) meetings. Islington CCG are also concerned about the Trust’s performance.

5.2.11 Jeanelle De Gruchy queried what action is being taken to address the deterioration in performance at the NMUH stroke unit. Jennie Williams confirmed that the Trust has a remedial action plan in place following a stroke service review. Ensuring that the Trust meets the TIA standard is part of this work.

5.2.12 The timeliness of discharges from NMUH has been identified as an ongoing concern. An action plan is in place to address workforce issues. Progress against this is being monitored by the CQRG.

5.2.13 Simon Caplan observed that the slow progress against the action plan is reaching the point where further escalation is required.

5.2.14 Catherine Herman also expressed concern about the lack of improvement in performance and quality at the Trust. She questioned whether this is the result of a lack of management capacity.

5.2.15 Sarah Timms also highlighted that NMUH had recently failed to appoint a Cancer Lead Nurse, which is also a concern.

5.2.16 Jill Shattock noted that NMUH have recruited an additional four Multi-Disciplinary Team Co-ordinators to improve the tracking of patients.

5.2.17 The Governing Body NOTED the Performance and Quality Summary Report.

6. Governance

6.1 Strategic Risk Report

6.1.1 Jennie Williams highlighted that two new risks had been added to the full Risk Register:

There is a risk that the North Central London STP does not recognise or support

the work of the Haringey and Islington Partnership as the agreed direction of

travel across all partners and therefore benefits to the population and

sustainable services are not realised

There is a risk that the uncertainty around the transition to the new North Central

London commissioning arrangements could adversely affect staff retention.

6.1.2 As these risks are both scored as ‘9’ at present, they had not been included in the Strategic Risk Report, which contains risks rated 12 and above.

6.1.3 It was anticipated that the score for Risk 35 (“There is a risk that NMUH will fail to achieve the NHS Constitution performance target for the 62 day cancer pathway”) would be reduced when NMUH reaches their cancer target.

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6.1.4 Simon Caplan queried whether Community Health Services should also be added to the Risk Register. Jennie Williams said that it was not considered a significant quality risk at this stage but the situation would continue to be monitored closely.

6.1.5 The Governing Body NOTED the Strategic Risk Report.

6.2 Conflicts of Interest Policy

6.2.1 Jennie Williams provided an overview of the pan-NCL generic Conflicts of Interest Policy which had been revised to take into account the new statutory guidance on managing conflicts of interest which had been published by NHS England earlier in the year. The key changes include a requirement for all partners of member practices to make a declaration in addition to those already required to do so, a requirement for new declarations to be submitted in future on a six-monthly basis, and a requirement for CCG staff, Governing Body and Committee members to complete annual online training. It was noted that the draft policy was in the process of being taken to all NCL Governing Bodies and was also being reviewed by the CCGs’ internal auditors, so it was possible that there may be additional minor changes.

6.2.2 In response to a query from Sarah Timms, Sarah Price noted that the CCG has no current plans to recruit a third lay member, which was one of the recommendations in the statutory guidance, but this position is being kept under review.

6.2.3 The Governing Body APPROVED the generic Conflicts of Interest Policy, subject to any further changes.

6.3 Clinical Cabinet Terms of Reference

6.3.1 The Governing Body APPROVED the revised Clinical Cabinet Terms of Reference.

7. For Information

7.1 Governing Body Committee minutes

7.1.1 The Governing Body NOTED the agreed minutes for the Clinical Cabinet meeting held on 1 September 2016, the Finance and Performance Committee meeting held on 22 September 2016, the North Central London Primary Care Joint Committee meeting held on 21 September 2016 and the Quality Committee meeting held on 24 August 2016.

8. Any Other Business

8.1 There was no other business.

9. Date of Next Meeting

9.1 Wednesday, 1 February 2017