Yes No - ealingccg.nhs.uk · opportunity to offer much better care for patients and our local population . The bringing together of primary medical services, community services and

Paper: 6

Date Wednesday, 08 February 2017

Presenter Neha Unadkat

Author Catherine Williams

Responsible Director

Tessa Sandall

Clinical Lead Dr Mohini Parmar

Confidential Yes ☐ No Items are only confidential if it is in the public interest for them to be so

The Board is asked to: Note progress

Summary of purpose and scope of report

This is a summary and further progresses the update given to the committee in November 2016.

Key headlines:

• The voting for Ealing CCG membership opened on 1st February 2017 and will close on 10th February 2017

• Once results have been verified by our Lay Chair the results will be announced by 17th February 2017

• We will officially announce all CCG results on 28 February 2017 to NHS England

• If the membership votes against delegated commissioning, we will rescind the application

• If the membership votes in favour of delegated commissioning, Ealing will take on management of Primary Care medical services from 01 April 2017

In order to support the vote a members’ assurance pack was shared with the membership and is attached for your information along with a covering letter from Dr Mohini Parmar, also attached.

Title of paper Primary Care Delegated Commissioning

Paper: 6

Conclusion: The committee will be provided with a monthly update to share progress.

Quality & Safety/ Patient Engagement/ Impact on patient services:

Finance, resources and QIPP

Equality / Human Rights / Privacy impact analysis

Risk Mitigating actions

Supporting documents

• Voting assurance details for delegated commissioning level 3 from Dr M Parmar • Members’ Assurance Pack: CCG due diligence information for members in advance

of voting on delegated Primary Care commissioning • Primary Care Commissioning Committee proposed TOR • Conflict of Interest approach and meetings protocol

Governance and reporting

Committee name Date discussed Outcome

3rd

Floor, Perceval House 14/16 Uxbridge Road

Ealing W5 2HL

26th January 2017

Sent by Email For the Attention of Senior GP Partners and Practice Managers Dear Colleagues Delegated Commissioning (Level 3) for Primary Care As you know, Ealing CCG has submitted an application to NHS England to move to Level 3 delegated Primary Care Commissioning from 1

st April 2017, pending a membership vote on whether or not to proceed.

The vote for Ealing CCG opens on 1

st February and will close at 5.00pm on 10

th February 2017.

We have held a number of meetings in recent months with all practices and the Council of Members, to discuss the benefits and risks of undertaking delegated commissioning. The CCG has found these meetings extremely useful in hearing your questions and ideas, and I am very grateful to you for your time and effort in contributing to our discussions. We have embarked on a rigorous due diligence exercise to examine the contractual and financial records held by NHS England, and to review the processes and policies that the CCG would need to put in place, if we decide to proceed. An assurance pack is included with this letter. Please read the summary in the first section; there is further detail in the second section, for your information. Many of you have asked questions about the appropriate governance process for delegated commissioning, and how to manage potential Conflicts of Interest. Also attached are terms of reference for the CCG’s Primary Care Commissioning Committee, and our planned approach to the effective management of Conflicts of Interest. We are very grateful for your feedback and continued input to this thinking. As a Clinical Commissioning Group, we believe that we will be able to commission services for patients more effectively if we take on full responsibilities for primary care commissioning. We anticipate that delegated commissioning will transfer from NHS England to CCGs nationally over the coming year, and we think there will be advantages for CCGs in taking that decision early on. I encourage you to make your views known in the coming vote, and to participate in our discussions following the vote. Yours faithfully

Dr Mohini Parmar

Chair

NHS Ealing Clinical Commissioning Group

Chair: Dr Mohini Parmar

Chief Officer: Clare Parker Managing Director: Tessa Sandall

CWHHE is a collaboration between the Central London, West London, Hammersmith & Fulham, Hounslow and

Ealing Clinical Commissioning Groups

Members’ Assurance Pack CCG due diligence information for members in advance of voting on delegated Primary Care commissioning January 2017

Purpose and Objectives

2

• The pack aims to provide members with the information they require in order to make an informed decision as to whether they wish to move the CCG from Level 2 co-commissioning to Level 3 co-commissioning.

• The initial slides provide an overview of information, covering our due diligence outputs, financial data, and precedent from other delegated CCGs.

• The later slides provide more detail. • The information provided builds on previous documents shared with you, to ensure you have

all the information you require.

The Vision for Primary Care in NW London

• We want to deliver the highest quality Primary Care measured by improved clinical and quality outcomes, patient experience and staff morale.

• We believe that delegated commissioning can strengthen our local General Practice. • We believe that delegated commissioning of primary care is a key enabler to the delivery of our Local

Services Strategy: delivering integrated out of hospital care, centred around General Practice. • We believe that the opportunity to commission Primary Care medical services offers us a unique

opportunity to offer much better care for patients and our local population.

The bringing together of primary medical services, community services and older people’s care, under Local Services Transformation, enables us to properly address issues, such as variations in the delivery of: • proactive, • accessible and • co-ordinated care. This also provides an opportunity to modernise services for our populations in a way that optimises the use of resources and targets resources more accurately and more efficiently.

Our vision for health and care in NW London is that everyone living, working and visiting here has the opportunity to be well and to live well. We know that the quality of care varies across NW London and that where people live can influence the outcomes they experience. We want to eliminate unwarranted variation to give everyone access to the same, high quality services.

Where we are now- summary

4

In summary, our progress to date includes: • Engagement We began our engagement with members’ back in October 2016. Since that time, there have been engagement events, such as: Council of Members meetings, drop in sessions, network meetings and NW London-wide discussions. We have utilised all the feedback and input from stakeholders to inform our documentation, plans and processes going forward. We have collated questions in a Frequently Asked Questions document, that we have circulated with comprehensive answers and further information (available at request), and collated more formal feedback from our governance meetings, such as Governing Bodies, Joint Co-Commissioning in Common meeting and Programme boards. • Process and project management We have utilised robust project management methodology to ensure we adhere to our tight timelines, whilst keeping members and stakeholders informed throughout the process. We have detailed this process in our recent Governing Body paper (presented at all eight Governing Bodies in January 2017). We initiated 3 due diligence workstreams to enable each of our eight CCGs’ memberships to analyse the risks and issues associated with delegated commissioning, and take an informed stance in advance of the voting period (30 January to 22 February 2017 across NW London). • What's next We are writing to members, by way of letter from their respective CCG Chair and this assurance pack. The final RSM financial and legal report will be circulated once received, on 30 January 2017. Once the voting period is complete, we are formally announcing the result to NHS England on 28 February 2017.

Due Diligence outputs - summary

5

• Governance We have begun to develop the governance structures and documentation required to support a move to level 3 co-commissioning, should the vote be in favour to support delegation. We have shared drafts with you, and incorporated feedback received. We are also developing an MoU with NHS England, as we stated in our application for delegation. This MoU, as part of our delegation agreement, will state that NHS England will do all it can to identify risks/disputes/ liabilities as at 31 March 2017 and make full provision in the 2016/17 annual accounts for such issues. • Finance & Legal RSM are due to complete their audit and report on 30 Jan, we will send this to you once received. Interim findings are explained in part 2 of this pack Responses to the practice survey have been low, at circa 35% across all NW London CCGs, however, it is being kept open longer, so please do respond if you have not already done so. Any feedback received before 30 Jan will be incorporated into RSM’s analysis. • Workforce NHS England staff currently managing Primary Care medical services will be seconded to us, based at Marylebone Road, but aligned to local CCG teams with significant travel to and presence in local CCGs. Current plans from NHS England suggest that we will also be in receipt of additional funding across all NW London CCGs to ensure we have the required workforce. We have also established a group to align our current CCG workforce, in order to maintain and build upon local relationships to support practice queries.

6

Learning from experience: Summary of outputs of delegated Primary Care Commissioning from other CCG Chairs

Kingston CCG

• Local decision making with a known person to contact

• Faster response to practice queries & issues – ability to provide interim support to practices with large numbers of registrations

• Clearer commissioning intentions to help practices provide services – local suite of KPIs, local commissioning plan that focuses on extended primary care, GP Referral Management Support, reducing non-elective admissions & GPs in A&E

• Quicker access to Primary Care funds • Local plans for practice changes (premises &

closures) – ability to provide interim support to practices with large numbers of registration

• Local oversight of the Improvement Grant process has unblocked a local application

Oldham CCG

• It has accelerated the implementation of the primary care strategy, and given it much more momentum.

• It has enabled more effective communication with and between practices, fostering productive relationships.

• It has helped the CCG work with practices to set standards for primary care.

• It has enabled practices to have a voice, and to be proactively involved in the development of local services and create ownership of their local plans.

• It helps to address inequalities by being able to respond to the local demographics and clinical needs.

• It has helped to stabilise general practice and retain GPs knowledge, skills and experience.

Risks and Challenges of Delegated Commissioning

7

Challenge Detail and planned mitigation Due Diligence

Making a smooth transition

CCGs will need to quickly adapt to manage new expectations and resolve any issues arising. We are preparing a transition plan to ensure a smooth transition to level 3, should members vote for delegation. We are defining a workforce model to ensure CCGs and any hub team across NWL will be able to respond quickly to members’ needs

Workforce

Role of CCG

Some of our stakeholders may be concerned if we pay more attention than previously to the issues affecting primary care. We believe that delegated commissioning will give members more control over new service design. CCGs will continue with open and transparent communications and engagement forums with all stakeholders

Governance

Resource

As this is a new responsibility for CCGs, there may be limited resources at first which will adversely affect the CCGs’ ability to undertake primary care commissioning. However, we believe we understand the resource requirements, and have begun to work through what we will need in terms of staffing and systems. The NHSE OD review has identified additional funding for staff to support Primary Care commissioning in NW London.

Workforce and Finance

Conflict of Interest (CoI)

The need to manage CoI increases at Level 3 where CCGs become responsible for primary care commissioning. Governing Bodies have prepared detailed policies and procedures designed to ensure a non-conflicted approach to decision-making. We are committed to keeping this clinically led in terms of the detailed operational models and strategy that will underpin it.

Governance

Quality improvement

Management of the national performers list is retained by NHS England. Decisions in relation to contract breaches, suspensions and terminations and quality improvements will be taken at the CCG’s committee, informed by advice from a group of experts local to North West London. We are learning from other CCGs’ experience, and considering setting up an Advisory Group across all NW London CCGs

Governance

Delivery of commissioning plans

The CCG’s ability to deliver our local strategies will partly depend on our ability to support our member practices’ plans and develop and deliver our primary care commissioning objectives. Implementation of the STP Plan across NW London will also depend upon successful engagement with our members to help realise our plans

Delegation executive

NHSE expectation

There may be an increased expectation from NHSE in contract management and complaints handling and adapting to their timeline. Although complaints management remains with NHSE, local leadership within each CCG will support member practices with issue resolution.

Workforce and Finance

Loss of focus

Since 90% of patient contact with the NHS is in primary care, dealing with public appeals and concerns may take CCG resource away from commissioning. We have begun detailed planning in terms of workload and workforce, both locally and across the STP footprint, to ensure that we adequately resource all necessary functions, as equitably and efficiently as possible.

Workforce

CCG Governing Body members have identified a number of the risks and challenges that may come with delegated commissioning (level 3). The table below shows how CCGs can mitigate each of the risks

Clearly defined objectives of delegated commissioning

8

Delegated commissioning arrangements are one of a set of changes set out in the NHS England, Five Year Forward View. Delegated commissioning arrangements for primary medical services (GP contracts) is seen as a key enabler in developing seamless, integrated out-of-hospital services based around the diverse needs of local populations. It is also expected to drive the development of new models of care such as multispecialty community providers and primary and acute care systems. Our objectives include: • GPs in CCGs to have direct leadership to influence the development of investment in general practice

• CCGs will be best placed to commission primary, community and secondary care in a holistic and integrated manner

• Ability to design local schemes to replace QOF and DES’s based on local knowledge

• CCGs will have more power to drive forward the five year forward agenda

• Greater, local freedom for investing in Primary Care

• Local decisions closer to patients needs

• Ability to use innovative commissioning to implement local priorities

• Better care for patients via joined up working

• Tailored services to meet the local needs of the patient population

• Local patients have greater opportunities to input and influence

• Ability to develop and commission end to end care

These objectives and benefits have been discussed with our Governing Body (January 2017)

We think that the opportunity is now – in taking charge of the primary care medical services budget to spend on primary care; to invest in the GP Forward View and the Strategic Commissioning Framework; to fund practices for Extended Access; to support practices in looking after managing their increasing workload and how to recruit and retain skilled staff – are worth the extra effort it will take, and the extra demands it will make on the CCG.

What happens if we vote yes?

9

• If the CCG membership votes in favour of delegation we will take on delegated commissioning on 1 April 2017. Business as usual will be maintained during the transition period.

• The CCG will continue engaging with members

• We will be able to deliver the agreed objectives of delegated commissioning, and proceed with our plans for the GP Forward View

• We will realise the benefits of delegated commissioning

• We will mitigate or absorb the risks of delegated commissioning

What happens if we vote no? • We will rescind our application and delegated commissioning will not begin on 01 April 2017

• The CCG will continue engaging with members

• We will not realise the benefits of delegated commissioning in 2017/18

• We will not be vulnerable to the identified risks of delegated commissioning

• Level 2 arrangements will continue, however, we anticipate that delegated commissioning will transfer from NHS England to CCGs nationally by 2018/19. We will work with NHS England to support CCGs in the interim period.

Members’ Assurance Pack

CCG due diligence information for members in advance of voting for delegated Primary Care commissioning

PART 2 – Further detail 10

Bromley Croydon

Barking and Dagenham

Barnet

Bexley

Brent Camden

Ealing

Enfield

Greenwich

H&F

Haringey Harrow

Havering

Hounslow

Islington

West London

Lambeth

Lewisham

Newham

Redbridge

Richmond

Waltham Forest

Wandsworth

Central London

Southwark

Hillingdon

Kingston Merton

Sutton

Sutton Croydon

Tower Hamlets

City & Hackney

Already delegated (11 CCGs)

Croydon

Approved (Regionally) for delegated (11 CCGs) Approved regionally but awaiting CCG S/O (10 CCGs)

It is important to note that NWL, C&H and Camden do not expect to have completed membership voting/ sign off until February 2017. (Camden are re-voting) 11

Expected delegation in 2017/18 (accurate December 2016)

Nationally, 63 CCGs opted for delegation in April 2015 and a further 52 did so in April 2016. More than half of all CCGs now hold delegated responsibility.

Engagement to date

12

• Since Ealing CCG initiated engagement surrounding delegated Primary Care commissioning in October 2016, we have collated all questions, comments, feedback and concerns into a ‘Frequently Asked Questions’ document.

• In total, we have 73 questions regarding governance, property issues, conflicts of interest, contracting, due diligence, resource and benefits of delegated commissioning.

• We have shared this document with our members at events, such as: Members meetings, locality meetings, Governing Bodies, and network meetings.

• We have managed our communications and engagement centrally, through our Virtual Primary Care team, comprised of Primary Care leads from all 8 CCGs.

• Outputs have fed into our Delegation Executive Steering Group, which has overseen the application process and engagement to date.

• We have launched our due diligence process, and are continuing to seek members’ input and informing them of plans and developments, to ensure that we remain open and transparent throughout this process.

• We have taken our progress date through all eight Governing Body meetings in January 2017, and provided the same information to members on 11 January 2017.

We have valued the discussions with our members, and have utilised their feedback to plan and implement a robust due diligence process, outputs of which are detailed in this pack.

Our critical success factors • Regular engagement with member practices and a culture of mutual trust.

• Having the right capacity and expertise to manage the contracts proactively and efficiently.

• Having a clear vision of what our CCGs want to achieve.

• Use of the process to strengthen and support General Practice.

Day 13 16 17 18 19 20 23 24 25 26 27 30 31 01 02 03 06 07 08 09 10 13 14 15 16 17 20 21 22 23 24 27 28 01 02 03 06 07 08 09 10 13 14 15 16 17 20 21 22 23 24 27 28 29 30 31 03

LST

Votin

g Fi

nanc

e W

orkf

orce

G

over

nanc

e

Last Updated: 16/01/17 KEY: Delegated Exec Steering Group

13 24 24 17 27 10 03 17 03 10 31

Brent Vote (30/01 – 12/02) 15 Harrow Vote

22 Hillingdon Vote

31 Central Vote

07 West Vote

H&F Vote (02/02 – 16/02)

15 Hounslow Vote

Ealing Vote (01/02 – 10/02)

02 West Proxy Vote

Launch

28 Vote Announced

Yes

No Rescind Applications

Delegation Start

18

What will RSM report look like? Assurance for report due on 30/01

20 - Sign off member

pack & letter

- MoU

23 Assurance Pack Sent Out

30 RSM Report

MD & COO Sign Off

19 Workforce Workshop 2

Governing Bodies

13 MoU Discussed

CoM (or equivalent)

20 MoU on Agenda for DESG

- Pre-Vote - MoU - Workforce update

- GB Paper - Workforce

- GB Paper Update - Vote

03

Agree MoU contents on Agenda for DESG

NHSE input into draft MoU

Feedback into Governance Docs and assurance pack

Feedback into Governance Docs

Governing Bodies 15

CWHHE & BHH GB Paper Deadline

25

NHSE to agree position & timeline for NHSE secondments into NWL

For endorsement Gaps, funding & structures agreed

Staff training scope Agree structures & wider workforce plans

For Noting Assurance report (due diligence report) also to Governing Bodies)

20 On Agenda for DESG

Assurance pack sent to members for vote

Governance Voting Finance Workforce Key Decisions

Delegation Action Plan for voting process

January February March

Member Meetings

Action Plan & Implement

Workforce Workshop 3 26

Scope & structure agreement

Report to Members – Final Assurance

Workforce Workshop 1

Governance documentation iterated following member, LMC and GB feedback (iterated drafts in assurance packs for voting) For ratification

LMC Roundtable 19

NHSE Event

17

• Vote result • Governance documentation • Due diligence report • Workforce structures and plans

Finalise MoU if yes vote

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Voting Procedure In order to prepare members for the vote for delegated commissioning, the voting wording is detailed below.

Members are invited to pass a vote on the following:

I agree to Ealing CCG taking on the responsibility for commissioning primary care medical services from 1 April 2017, under fully delegated (level 3) arrangements from NHS England [agree / disagree]

As a consequence, I agree that the following actions will be taken:

1) That Ealing CCG will establish a committee of the governing body in order to carry out these functions.

2) The final terms of reference, once ratified by the governing body, will be adopted into the CCG's constitution, and members will recognise these as having effect from 1 April 2017

Application Process: revisiting the application caveats

15

NW London CCGs each submitted applications to NHS England on 05 December 2016 to take on delegated Primary Care commissioning from 01 April 2017, with agreed caveats. All of our applications state:

“NW London CCGs apply for delegated commissioning arrangements with the explicit understanding and agreement with NHS England that it will not progress without membership support, in accordance with each CCGs’ constitution. We are holding a membership vote that will commence on 01 February 2017 and the results will be made public on 28 February 2017. If the membership does not vote in favour of moving to delegated Primary Care commissioning, the CCG will rescind this application. This application is dependent on the CCG undertaking robust due diligence surrounding workforce, finance, governance and legal implications associated with Primary Care commissioning. The CCG will require local granularity in terms of practice-level information to complete this process. The CCG will be indemnified against legacy issues. If the outputs of these reviews indicate the CCG is not in a position to commission Primary Care services on the basis of financial implications, including resourcing issues, the application will be reviewed, and potentially rescinded. It is expected that a Memorandum of Understanding will be agreed between NHS England and the CCG before delegated commissioning commences that includes: • Clauses to indemnify the CCG against legacy related issues; and • Confirmation that NHS England remains both accountable and responsible for counter-fraud (or an explanation if the

CCGs are to be held responsible for local delivery, as to how this will be resourced and managed between the CCGs’ Audit Committee and NHS England’s own Audit Committee).”

The application was agreed at NHS England (London) moderation panel on 09 December, and was submitted to NHS England (National) for approval on 20 December 2016. Subsequently NW London have received informal feedback that the application was approved at the national panel, and is being formally ratified at the national commissioning committee. We are now working with NHS England to develop our Memorandum of Understanding, to provide the necessary indemnification against historical issues and related matters.

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Memorandum of understanding: Legacy issues

Legacy Issues: With regard to historic issues and for CCGs taking full delegation from 1st April 2017, NHS England will remain liable for any pre April 2017 liabilities. As far as possible potential issues will be captured on NHSE’s legacy list and provision will be made for these ‘old-year’ liabilities. Agreement: We are seeking agreement with NHS England, as part of our delegation agreement, that NHS England will do all it can to identify risks/disputes/ liabilities as at 31 March 2017 and make full provision in the 2016/17 annual accounts for such issues. NHS England (London) and the CCGs will agree that if other unforeseen issues arise, both parties will use best endeavours to jointly mitigate the liability and the NHSE London region will use the all the flexibility it has to fund the pre April 2017 elements, although CCG decisions which incur a new commitment pre 1 April 2017 will be a CCG responsibility. Process: We are in the process of developing this agreement. We are currently gaining input from the CCGs and in discussions with NHS England. Once we have a final version agreed we will share this with members and the LMC.

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Overview Due Diligence Process • In order to ensure that our CCGs are prepared to take on fully delegated commissioning, should membership vote in favour,

NW London have undertaken due diligence in the key areas of finance, governance and workforce.

• Each workstream reports into the Delegation Executive Steering Group (membership includes all MD/COOs, AOs, Lay Reps, Governance lead, Finance Lead, Workforce lead)

• As well as ensuring that each workstream is on track, the group also endorse any key decisions for ratification at Governing Bodies (or at the appropriate forum) . Information is disseminated to each CCG through the set governance and engagement routes, and feedback is centrally collated.

To ensure we implement robust governance procedures and principles required for level 3

To ensure CCG Governing Bodies consider the financial risks associated with the proposed transfer of responsibilities for the management of Primary Care contracts from NHS England from 1 April 2017.

Review of staff capacity to ensure that contract management, commissioning, finance, admin, business intelligence and lay member is equitable and resourced appropriately.

Supporting on-going operational processes, and ensuring these operate smoothly at level 3 – GP contracts, payments and communications

Operational processes – on-going

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Financial Due Diligence: Overview

• RSM have begun to analyse practice survey responses, and the obtained financial and contractual information received from NHS England. A final report is due on 30 January 2017; which will be shared with members once received.

• We have collated stakeholder feedback, comments, ideas and suggestions regarding our proposed move to delegated commissioning. Member Practices, the LMC, and local patients have come to a number of sessions to discuss this over the last 3 months, and we appreciate the commitment of time this has meant for practices.

• NHS England has asked CCGs to explore taking on fully delegated commissioning from this April – in other words, to be responsible for most decisions on local primary care. This means more local say, however, this does mean an extra demand on CCG time.

• The CCG takes very seriously our responsibilities for commissioning services. We believe Primary Care medical services need input from the people who understand primary care the best – the practitioners who work in primary care every day.

• Practices have told us that they urgently want support, resources – money, people and thinking-time – and better facilities to improve services for their patients. Practices can see the needs of their patients but don’t always have the time and money and clout to meet those needs. CCGs can see what practices need but don’t always have the tools to make things happen. This has been frustrating for GPs, practice staff and the CCG.

• We think that the opportunity is now – in taking charge of the primary care medical services budget to spend on Primary Care; to invest in the GP Forward View and the Strategic Commissioning Framework; to fund practices for Extended Access; to support practices in looking after managing their increasing workload and how to recruit and retain skilled staff. We believe this is worth the extra effort it will take, and the extra demands it will make on the CCG.

• Delegated commissioning does NOT mean ‘more interference’. We believe that local control over ‘Primary Care commissioning’ can be better for GPs, our practices and our patients.

FINANCE- issues from practices Summary of investigations to date

What is the status of practice contracts, on-going rent reviews, etc., across the CCG?

We have commissioned RSM to get full details from NHSE of all practice contracts, dates of completed and outstanding rent reviews. We have also asked all practices to fill in a questionnaire to highlight any outstanding contract issues for our information. Our current response rate is 35% across NW London – please urge practices to respond (survey has been extended until end of week) so that we can get a balanced view of the concerns and issues across NW London.

Will NHS England pass on a deficit budget for primary care?

Individual CCG budgets in NW London reflect a variety of positions; two CCGs are currently in deficit and six CCGs have a surplus. There is a collective surplus for our STP footprint as a whole. Members are asked to note that, whilst the 2017/18 NW London finance strategy has yet to be considered by the CCGs’ F&P committees and governing bodies, this is our usual mechanism for addressing such variations and is thus our current preference for so doing. NHSE has confirmed that, if any liabilities appear for the period up to 31 March 2017, they will indemnify (reimburse) the CCG under a best endeavours arrangement.

My practice has undertaken capital improvements, and the rents and running costs are likely to rise. Will the CCG cover these?

The same national rules will apply to what is reimbursed to practices, regardless of who commissions the services

Will the service improve in getting responses to my queries?

We are planning to set up local arrangements so that local practices can get a quicker response to practice queries. We are also negotiating with NHSE to get additional staff to support improvements in service. However, some aspects will stay the same: NHS England will continue to hold GP contracts, and they will still manage the support contract with Capita and the national performers’ list.

Can Primary Care funding be spent to bail out acute hospital deficits?

No. Primary care funding allocations are ring-fenced to be spent on Primary Care services.

19

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Workforce Due Diligence: Overview

“How will Primary Care commissioning be adequately resourced”? • A Task & Finish Group was set up to lead this due diligence process

• Initial finding highlighted capacity and capability issues, as well as gaps in key functions e.g., business intelligence, and quality & performance, within the existing commissioning and contracting portfolio.

• We have agreed across NW London that:

• Primary Care management;

• Relationships; and

• Decision making

• need to be local to each CCG, however, there are some functions where it makes sense to concentrate expertise and share resources across the eight CCGs by aligning to existing shared teams, e.g., technical contract support, business intelligence.

• This will enable primary care resources and skills to be used to best effect. • NHS England staff will be seconded to NW London, based at Marylebone Road, but will be aligned to local CCG teams with

significant travel to and presence at local CCG offices

• The strategic planning leads across London realised the need to distribute central primary care resource more equitably across London. As a result NW London will receive an additional establishment budget to support delegated commissioning. The amount is yet to be finalised but will be in the region of £177k.

• The London-wide OD Review is working on an STP footprint basis, and are currently developing an MoU to this effect, detailing the transfer of staff and will outline how staff will continue to be managed under the delegated arrangements. This is due for finalisation on 28 February 2017.

• Finally, the above approach will be underpinned by consistent engagement with CCG leads and other colleagues, along with an agreed transitions plan for the period March 2017 to June 2017.

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Governance Due Diligence: Context Since we last wrote to you with our first iteration of our governance documentation: • Draft structure of the proposed Primary Care Commissioning Committee (to replace the current co-commissioning committee,

should members chose to delegate); • Draft Terms of Reference for such a committee; and • Conflicts of Interest Management plan.

We have since incorporated feedback from members, patients, LMC, and Governing Bodies The proposal is that the material points, once fully collated, are reviewed by the governance working group together with governance leads representatives before a recommendation is made in the first instance to the delegation executive steering group and secondly to the NW London CCGs’ chairs’ group contingent upon what the material differences may be that may need to be decided upon. TOR: The final ToR are due to be ratified by governing bodies in March 2017 MoU: A joint meeting was held between NW London CCGs and NHS England to discuss the approach to the memorandum of understanding. Conversations are underway with estates and finance colleagues. An iteration of this was discussed by the governance working group on Wednesday 18 January, which included the Audit Committee chairs. The document will be updated following the exec steering group on Friday 20 January, where any outstanding queries will be identified. We are developing this with NHSE, and our plan is to have it in place by 01 April 2017. NW London Contracts Action Advisory mechanism: information gathering is underway to understand the volume and nature of contracts issues (remedial; breach; suspensions; terminations) that the local committees have dealt with during 2016/17 at Level 2 of joint commissioning arrangements. This will help to inform the shape and frequency of an NW London-wide advisory mechanism. We note LMC feedback that LMC should be represented. In summary: • The final proposed documents will be ratified by the governing body in March 2017.

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Governance Due Diligence GP members and voting rights • Statutory guidance issued by NHSE on 29 June 2016 strongly recommends that GP members of primary care commissioning

committees do not have voting rights. • This is in order to protect GPs and the CCGs from both real or perceived conflicts of interest. • New NHSE guidance is due to be published in early 2017 further to the public consultation on management of conflicts of interest

across the NHS as a whole and will supersede the June guidance. • Currently, GP members of our Primary Care co-commissioning committees (at Level 2) do have voting rights, with the onus being on

committee Chairs, executive leads and governance staff to carefully and pro-active manage of conflicts of interest. The formal recommendation of the NW London CCG’s conflicts of interest reference group is that local area GPs do not have voting rights at Level 3 of delegated arrangements, but that local area GPs are included in the membership, with independent clinicians being included among the committee’s voting members. • Feedback to date:

• Some stakeholders have queried the voting rights of GPs. This has been raised by LMC and Governing Bodies. Discussion at Governing Bodies has largely agreed with NHSE guidance, that GPs should not have voting rights is they have real or perceived conflicts of interest. It has been raised that Primary Care input is obviously essential to the committee, and that out of area GPs, or GP advisors must be part of the voting group.

• Primary Care decisions will not be made in silo; discussions will be had at Exec forums, CoMs, GB seminars and related forums before decisions are taken at the new Primary Care commissioning committee. It is envisaged that the Governing Body will remain the strategic driving force for the CCG.

• Our current Conflicts of Interest approach is included as appendix 2

Conflict of Interest Key principle: • A key principle is that our updated COI arrangements will seek to ensure the optimal balance between achieving a strong

clinical voice, whilst at the same time robustly protecting both CCGs and individual decision-makers from exposure to any real or perceived conflicts of interest.

23

Governance Due Diligence: Membership The approach to our new governance arrangements will be driven by the following principles: • Ensuring that the clinical voice is optimised whilst at the same time safeguarding GPs and the CCG from real or perceived conflicts of

interest; • Ensuring that both local and joint working is effective and transparent to the CCGs and to all stakeholders, and that it delivers the

objectives set out in our NW London STP; and • Ensuring that decision-making remains fully compliant with statutory guidance and that it reflects good governance practice and is

evidence-based.

Feedback to date:

• LMC would like additional representation on the committee (one secretary, one Chair). This is duly noted.

Terms of Reference (general comments) • We have had detailed comments on the ToR, and have a revised version attached, due to be ratified by the governing body in March.

• It now includes the connection to the CCGs’ responsibility for quality

• Adapted the voting membership to include 3 voted GB members, which may include GPs, nurses or practice managers, who will be elected by the membership.

• Concern has been expressed that four of six voting members may be difficult to achieve, therefore it is proposed this is reduced from four to three voting members and adopted by all committees. All three of the categories listed (lay; officer; clinician) are vital for the decision-making process therefore have been retained.

• Other amendments (and changes to the previous version) are included in the ToR

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Next steps

• You are due to vote between 1st and 10th February 2017 • Once results have been verified by our Lay Chair the results will be announced by 17th February

2017 • We will officially announce all CCG results on 28 February 2017 to NHS England • If your membership votes against delegated commissioning, we will rescind the application • If your membership votes in favour of delegated commissioning, Ealing will take on management

of Primary Care medical services from 01 April 2017

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Appendices

• Appendix 1: Terms of Reference for the proposed Primary Care commissioning committee

• Appendix 2: CoI approach

1

NWL CCGs’ primary care commissioning committee draft terms of reference

[NWL CCG name] CCG’s Primary Care Commissioning Committee

Terms of Reference (to be ratified in March 2017)

1 Purpose and statutory framework

1.1 In accordance with its statutory powers under section 13Z of the National Health Service Act 2006

(as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 to

these Terms of Reference to [name] CCG.

1.2 The CCG has established the [name] CCG Primary Care Commissioning Committee (“Committee”).

The Committee will function as a corporate decision-making body for the management of the

delegated functions and the exercise of the delegated powers.

1.3 Arrangements made under section 13Z may be on such terms and conditions (including terms as

to payment) as may be agreed between NHS England and the CCG.

1.4 Arrangements made under section 13Z do not affect the liability of NHS England for the exercise

of any of its functions. However, the 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 and including:

a. Management of conflicts of interest (section 14O);

b. Duty to promote the NHS Constitution (section 14P);

c. Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d. Duty as to improvement in quality of services (section 14R);

e. Duty in relation to quality of primary medical services (section 14S);

f. Duties as to reducing inequalities (section 14T);

g. Duty to promote the involvement of each patient (section 14U);

h. Duty as to patient choice (section 14V);

i. Duty as to promoting integration (section 14Z1);

j. Public involvement and consultation (section 14Z2).

1.5 The CCG will also need to specifically, in respect of the delegated functions from NHS England,

exercise those in accordance with the relevant provisions of section 13 of the NHS Act, such as

regards impact on services in certain areas and variation in provision of health services.

1.6 The Committee is established as a committee of the Governing Body of [Name] CCG in accordance

with Schedule 1A of the “NHS Act”.

1.7 The Committee is formally accountable for furnishing the Finance and Audit Committees with the

formal reports it requires to assure the CCG Governing Body that Primary Care delegation is being

effectively governed and managed. It will additionally report to the Quality Committee in order

that the CCG’s approach to quality is consistent and can be understood alongside the CCG’s other

areas of commissioning responsibility.

2. Secretariat

2.1 The CCG will provide secretariat support to the Committee including preparation and distribution

of papers, the taking of minutes and facilitating agendas. Additionally, the secretariat will support

2


the pro-active and careful management of conflicts of interest, in accordance with the CCG’s

conflicts of interest management policy.

2.2 The secretariat will be responsible for supporting the Chair in the management of the

Committee’s business and for drawing the Committee’s attention to best practice, national

guidance as it emerges, and other relevant documents as appropriate.

2.3 A record of actions and decisions will be circulated by the secretariat to the Committee within five

working days. The minutes/notes as agreed by the Committee Chair, will be circulated to

attendees of the Committee at the latest within 15 working days of each Committee meeting.

3. Frequency and notice of meetings

3.1 The Committee will typically convene monthly and in public.

3.2 Papers will be issued no later than five working days before each meeting. The dates of the

meetings and papers will be available on the CCG’s website.

3.3 The Committee may resolve to exclude the public from a meeting that is open to the public

(whether during the whole or part of the proceedings) whenever publicity would be prejudicial to

the public interest by reason of the confidential nature of the business to be transacted, or for

other special reasons stated in the resolution and arising from the nature of that business or of

the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings)

Act 1960 as amended or succeeded from time to time.

4. Authority and reporting

4.1 The Committee is established under [name] Clinical Commissioning Group’s constitution as a

committee of the Governing Body and will make decisions within the bounds of its remit.

4.2 The Committee will present its minutes and an executive summary report to NHS England London

Region and the Governing Body for information.

4.3 There is a statutory requirement that the Committee publishes a register of its decisions, outlining

the management of any Conflicts of Interest. This shall be made available via the CCG’s website.

4.4 The Committee may delegate tasks to such individuals, sub-committees or individual members as

it shall see fit, provided that any such delegations are consistent with the agreement entered into

between NHS England and [name] CCG, are recorded in a scheme of delegation, are governed by

appropriate terms of reference and reflect appropriate arrangements for the management of

conflicts of interest.

5. Membership

Voting members (lay and executive majority)

• Governing Body Lay Member, [name] CCG (Chair)

• Governing Body Lay Member, [name] CCG (Vice Chair)

• CCG Managing Director/Chief Operating Officer, [name] CCG, or their deputy

• CCG Chief Finance Officer, or their deputy

• Non-conflicted clinicians x 2 (secondary care doctor / nurse / out-of-area GP / allied health

professional)

3


Non-voting members

• NHS England representative

• Three elected Governing Body members, [name] CCG

• Heads of Primary Care (CCG; seconded NHSE staff)

• Public Health borough representative

• Local authority representative of borough Health and Wellbeing Board

• HealthWatch borough representative

• Local Medical Committee representative

No person who is a practising GP in the CCG area may be a voting member of the Committee.

6. Quoracy, voting and confidentiality

6.1 The quorum shall comprise of a minimum of three voting members and include at least one lay

member, one CCG officer and one clinician.

6.2 The Committee shall have a non-conflicted majority at all times.

6.3 Each voting member of the Committee shall have one vote. The Committee shall reach decisions

by a simple majority of members present, but with the Chair having a second and deciding vote, if

necessary. However, the aim of the Committee will be to achieve consensus decision-making

wherever possible.

6.4 Members of the Committee, with agreement from the Chair, may send a designated deputy with

full authority if they cannot attend in person.

6.5 Members of the Committee shall respect confidentiality requirements as set out in the CCG

Constitution or Standing Orders.

7. Remit and responsibilities

7.1 The Committee recognises that the rationale for NHSE’s delegation of primary care medical

services commissioning to the CCG is to increase quality, efficiency, productivity and value for

money, and to remove administrative barriers, which in turn will serve to strengthen and stabilise

general practice.

7.2 In performing its role, the Committee will exercise its management of the functions in accordance

with its terms of reference, delegation of authority and the agreement entered into between NHS

England and [name] CCG.

7.3 The role of the Committee shall be to carry out the functions relating to the commissioning of

primary medical services under section 83 of the NHS Act. This includes the following:

a. GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring

of contracts, taking contractual action such as issuing branch/remedial notices, and removing

a contract);

b. Providing assurance to the Governing Body and NHS England on quality, performance and

finance of all services commissioned from primary care which incorporate the delegated

funding and funding from the core CCG allocation (for example prescribing, incentive schemes

and local primary care contracts).

4


c. Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced

Services”);

d. Design of local incentive schemes as an alternative to the Quality Outcomes Framework

(QOF);

e. Decision making on whether to establish new GP practices in an area;

f. Approving practice mergers; and

g. Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).

h. Agreeing and monitoring a financial plan and budget; risk assessment, performance

framework and annual workplan.

7.4 The CCG will also carry out the following activities, in collaboration with other NWL CCGs:

a. To plan, including needs assessment, primary medical care services in the [name] area;

b. To undertake reviews of primary medical care services in the [name] area;

c. To co-ordinate a common approach to the commissioning of primary care services generally;

d. To manage the budget for commissioning of primary medical care services in the [name] area;

7.5 The Committee is accountable for exercising the agreed delegated functions from NHS England.

The agreed delegated functions are set out in Schedule 2. NHSE retains the responsibility for

individual practitioner performance whilst the CCG will have responsibility for practice contract

performance.

8. Governance structure and effectiveness

8.1 The Committee will be responsible for seeking assurance in order that strategy, commissioning,

performance, quality and finance considerations guide and inform effective primary care medical

services commissioning.

8.2 The Committee will ensure, on behalf of the Governing Body, the effective design and delivery of

primary care medical services to meet the needs of our local population, in line with the CCG’s

long-term strategic objectives, as expressed in the Sustainability and Transformation Plan (STP)

for the borough and for North West London.

8.3 The Committee shall remain the decision-making committee for all areas within its remit, whilst

taking due account of any recommendations and reviews that may from time to time be provided

by other committees of the CCG’s Governing Body.

8.4 The Committee may appoint ad-hoc members to advise it on specific matters within its terms of

reference from time to time as appropriate.

8.5 The Committee shall review its own effectiveness after its first six months and annually

thereafter, and submit any proposed changes to its terms of reference to the Governing Body for

ratification.

9. Sub-structure

The joint committee may establish local task and finish groups as required (which will operate as non-

decision making working groups); these will be properly constituted with terms of reference approved by

the Committee. Where appropriate, existing committees will be reviewed and refreshed to support the

effective delivery of the new functions of this Committee.

5


Version: 24 January 2017

These terms of reference remain subject to formal ratification by CCGs at the governing body meetings due to be held in

March 2017.

6


Appendix

Delegation Agreement

The core provisions of the Delegation Agreement (such as those set out at Schedules 1 and 2, below)

form part of the committee’s terms of reference. This Delegation Agreement will be complemented by

the detailed Memorandum of Understanding between the CCG and NHS England, which remains under

development.

1. In accordance with its statutory powers under section 13Z of the National Health Service Act

2006 (as amended) (“NHS Act”), NHS England has delegated the exercise of the functions

specified in this Delegation to [insert name] CCG to empower [insert name] CCG to commission

primary medical services for the people of [insert area].

2. NHS England and the CCG have entered into the Delegation Agreement that sets out the

detailed arrangements for how the CCG will exercise its delegated authority.

3. Even though the exercise of the functions passes to the CCG the liability for the exercise of any

of its functions remains with NHS England.

4. In exercising its functions (including those delegated to it) the CCG must comply with the

statutory duties set out in the NHS Act and/or any directions made by NHS England or by the

Secretary of State, and must enable and assist NHS England to meet its corresponding duties.

Commencement

5. This Delegation, and any terms and conditions associated with the Delegation, take effect from

1 April 2017.

6. NHS England may by notice in writing delegate additional functions in respect of primary

medical services to the CCG. At midnight on such date as the notice will specify, such functions

will be Delegated Functions and will no longer be Reserved Functions

Role of the CCG

7. The CCG will exercise the primary medical care commissioning functions of NHS England as set

out in Schedule 1 to this Delegation and on which further detail is contained in the Delegation

Agreement.

8. NHS England will exercise its functions relating to primary medical services other than the

Delegated Functions set out in Schedule 1 including but not limited to those set out in Schedule

2 to this Delegation and as set out in the Delegation Agreement.

Exercise of delegated authority

9. The CCG must establish a committee to exercise its delegated functions in accordance with the

CCG’s constitution and the committee’s terms of reference. The structure and operation of the

committee must take into account guidance issued by NHS England. This committee will make

the decisions on the exercise of the delegated functions.

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10. The CCG may otherwise determine the arrangements for the exercise of its delegated

functions, provided that they are in accordance with the statutory framework (including

Schedule 1A of the NHS Act) and with the CCG’s Constitution.

11. The decisions of the CCG Committee shall be binding on NHS England and [insert name] CCG.

Accountability

12. The CCG must comply with the financial provisions in the Delegation Agreement and must

comply with its statutory financial duties, including those under sections 223H and 223I of the

NHS Act. It must also enable and assist NHS England to meet its duties under sections 223C,

223D and 223E of the NHS Act.

13. The CCG will comply with the reporting and audit requirements set out in the Delegation

Agreement and the NHS Act.

14. NHS England may, at its discretion, waive non-compliance with the terms of the Delegation

and/or the Delegation Agreement.

15. NHS England may, at its discretion, ratify any decision made by the CCG Committee that is

outside the scope of this delegation and which it is not authorised to make. Such ratification

will take the form of NHS England considering the issue and decision made by the CCG and then

making its own decision. This ratification process will then make the said decision one which

NHS England has made. In any event ratification shall not extend to those actions or decisions

that are of themselves not capable of being delegated by NHS England to the CCG.

Variation, Revocation and Termination

16. NHS England may vary this Delegation at any time, including by revoking the existing Delegation

and re-issuing by way of an amended Delegation.

17. This Delegation may be revoked at any time by NHS England. The details about revocation are

set out in the Delegation Agreement.

The parties may terminate the Delegation in accordance with the process set out in the Delegation

Agreement.

Signed by [confirm current post-holder]

Chief Financial Officer

for and on behalf of NHS England

8


Schedule 1 – Delegated functions at Level 3 of primary care commissioning arrangements

[Those functions delegated from NHS England to the CCG]

a. decisions in relation to the commissioning, procurement and management of Primary

Medical Services Contracts, including but not limited to the following activities:

i. decisions in relation to Enhanced Services;

ii. decisions in relation to Local Incentive Schemes (including the design of such schemes);

iii. decisions in relation to the establishment of new GP practices (including branch

surgeries) and closure of GP practices;

iv. decisions about ‘discretionary’ payments;

v. decisions about commissioning urgent care (including home visits as required) for out of

area registered patients;

b. the approval of practice mergers;

c. planning primary medical care services in the Area, including carrying out needs assessments;

d. undertaking reviews of primary medical care services in the Area;

e. 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);

f. management of the Delegated Funds in the Area;

g. Premises Costs Directions functions;

h. co-ordinating a common approach to the commissioning of primary care services with other

commissioners in the Area where appropriate; and

i. such other ancillary activities as are necessary in order to exercise the Delegated Functions.

Schedule 2 – Reserved functions

[Those functions which NHS England will continue to be responsible for]

a. management of the national performers list;

b. management of the revalidation and appraisal process;

c. administration of payments in circumstances where a performer is suspended and related

performers list management activities;

d. Capital Expenditure functions;

e. section 7A functions under the NHS Act;

f. functions in relation to complaints management;

g. decisions in relation to the Prime Minister’s Challenge Fund; and

h. such other ancillary activities that are necessary in order to exercise the Reserved Functions;

9


Annex 2 – Committee membership

Figure 1 – Primary Care Commissioning Committee core structure

Other officers shall have a standing invitation to attend meetings of the Primary Care Commissioning Committees as required to advise on and enact the business of the committees. The committee may choose to exclude non-voting members from certain items of the private meeting when considered appropriate, with particular attention paid to the application of the conflicts of interest policy. Committees will be chaired by a Lay Member of the Governing body. The Vice Chair will also be a Lay Member. Neither the Chair nor the Vice Chair will be the Lay Member responsible for Audit. The membership above represents the common core and minimum membership across the eight proposed committees – local variation from this agreed core may be recorded in the Terms of Reference for the boroughs, although these are intended to be minimal. Committees may wish to include public health representatives in their membership.

10


Annex 3 – proposed governance structure and operating model

Figure 2 – Primary Care Commissioning governance and operating model

Item x (Document x), January 2017

1

Appendix 2 - Delegated primary care commissioning (Level 3)

Decision-making and approach to managing conflicts of interest

Detailed arrangements for decision-making are described in the terms of reference at Appendix 1 (which are

subject to ratification in March, pending the outcome of the vote).

Our full conflicts of interest management policy is due to be updated in early 2017 pending new NHSE guidance

due to be issued. In summary, the following principles will underpin our approach:

decisions will be made by consensus wherever possible;

where voting is required, decisions will be made by a simple majority;

voting members of the committee will be non-conflicted lay and executive members, plus any

independent clinician members (on this last cadre, see final bullet below);

all voting members in attendance may vote (subject to the CCG’s conflict of interest policy);

where there is a split decision, the chair will have a second, deciding vote;

our quorum is subject to ongoing discussions, is planned to be drawn from voting members, and will be

aligned with our conflicts of interest management policy;

substitutions for members must be taken from named deputies and approved by the Committee Chair;

and

clinical representation in the vote will be provided by independent clinicians to be appointed to the

committee (pending local discussions, and where necessary, recruitment). This may include any of: a

registered nurse, a secondary care consultant, an allied health professional, or an out-of-area GP.

At Level 2 of delegated arrangements, GPs members are currently able to vote on decisions subject to the CCG’s

Conflict of Interest policy. However, it is proposed that, in line with the most recent statutory guidance (which at

the time of writing was issued by NHSE on 29 June 2016), local area GPs do not have voting rights.

Summary meetings management protocol and attendance

Each CCG’s primary care commissioning committee will be a formal committee of its respective governing body.

As such, each will be subject to the controls outlined in the relevant constitution and supporting policies.

Arrangements for the committee will include:

meetings to be held regularly and are proposed to be monthly;

meetings may be held in common where there is common business to conduct;

meetings will be held in public, with a facility for a closed session to enable confidential business to be

transacted;

agendas for meetings will be developed by the CCG’s commissioning team together with the North West

London Virtual Primary Care Team – to include joint activities across North West London as appropriate;

agendas will be reviewed for potential conflicts of interest and to make arrangements for managing

conflicts of interest. The conflicts of interest policy for each CCG will be enacted for each meeting and

applied to all relevant business wherever it is undertaken;

the Lay Committee Chair will be briefed on the agenda, confirmed attendees and conflicts of interest in

advance of the meeting;

agenda and papers will be published five working days in advance of the meeting;

proceedings will be formally minuted and the minutes of public meetings will be published;

a continuous log of decisions shall be maintained and made available via the CCG’s website; and

decisions made at committees will be enacted as part of business as usual by the commissioning teams in

each borough and the North West London primary care contracting teams;

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