Governing Body Meeting - Part I Agenda

Governing Body Meeting - Part I Agenda

Tuesday, 27 January 2015, 14.30 – 16.35 Theatre Room, Oxford House, Derbyshire Street, Bethnal Green, London E2 6HG

1 General Business

Action required Presenter Enc. Time Page

1.1 Welcome, introductions and apologies

-

Cate Boyle Verbal

14.30 (10 mins)

-

1.2 Declarations of interest -

1.3 Chair’s report To note 5

1.4 Chief Officer’s report Jane Milligan

1.5 Patient’s Story

To note Video 14.40

(10 mins) -

1.6 Minutes and matters arising of the meeting held November 4th 2014

To approve Cate Boyle 14.50

(5 mins) 11

2 Performance and operations

2.1 Board Assurance Framework

To note Jane Milligan 14.55

(5 mins) 27

2.2 TH CCG Objective Scorecard

To note John Wardell 15.00

(5 mins) 53

2.3

Finance and Activity • 2.3.1 Finance report

Month 8

• 2.3.2 Activity report

To note

Henry Black

Huw Wilson-

Jones

15.05 (15 mins)

57

71

2.4

Performance and Quality report To note Archna

Mathur 15.20

(15 mins)

77

2.5 Healthwatch – Annual report For

information Dianne Barham

15.35 (15 mins)

87

5 minute break

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3 Commissioning and strategy

3.1

Allocations update To note

Henry Black

15.55

(5mins) 103

3.2

Primary Care Co-commissioning Please note the full proposed Constitution with amendments can be viewed on the Tower Hamlets CCG website: http://www.towerhamletsccg.nhs.uk/Publications/our-constitution---new.htm

For approval

Rahima Miah / Jane

Milligan

16.00

(15mins) 111

3.3 CHS Re-procurement update For

information

Maggie Buckell / Nigel Woodcock

16.15

(10mins) 245

4 For information

4.1 Audit Committee summary

To note

Mariette Davis

16.25

(5 mins)

257

4.2 Transformation and Innovation Committee

Maggie Buckell 259

4.3 Finance, Performance and Quality Committee summary

Jane Milligan

261

4.4 Locality Board summary 263 4.5 Executive Committee summary 265

4.6 Equality and Diversity Committee summary

Dr Haroon Rashid 267

5 Other Business items

6 Questions from the public 16.30

All questions received 48 hours before the meeting in will be recorded in the minutes of the meeting. If you are asking a question at the meeting please use the sign in sheet in the public area of the meeting. You will be asked for your name and the agenda item number your question refers to. You will be expected to retain a copy of your question. Questions that are asked verbally at the meeting will only be answered if an accurate answer can be provided. Otherwise, the question will be taken on notice and will be answered at the next meeting. Please email [email protected] for more information.

7 Date of next meeting

Meeting in public March 3rd 2015 – 14.30 Osmani Centre, 58 Underwood Road, London E1 5AW

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http://www.towerhamletsccg.nhs.uk/Publications/our-constitution---new.htm

http://www.towerhamletsccg.nhs.uk/Publications/our-constitution---new.htm

mailto:[email protected]

Public information sheet

Attendance at meetings

The public are welcome to attend the Governing Body meeting of NHS Tower Hamlets CCG

Getting here by bus Bus routes to Bethnal Green Road include routes 8, 388 and D3.

Getting here by rail Shoreditch High Street station is a 15-20 minute walk away or alternatively take bus route 8 or 388 towards Bethnal Green Road.

Fire alarm

If the fire alarm sounds please leave the building by the nearest available exit without deviating to collect your belongings. The meeting will reconvene if safe to do so.

Electronic agenda, reports and minutes

Copies of agenda, reports and minutes for CCG meetings can be found on our website 4 working days before the meeting:

http://www.towerhamletsccg.nhs.uk/Publications/governing-body-papers.htm

Documents can be made available in large print, Brail or audio version. For further information, contact [email protected].

Questions from the public The Governing Body welcomes questions from the public. There are two ways the public can ask the Governing Body a question:

In advance of the meeting At the meeting All questions received 48 hours before the meeting in will be answered and recorded in the meeting.

Please email [email protected] with your question.

If you are asking a question at the meeting please use the sign in sheet in the public area of the meeting.

You will be asked for your name, your question and the agenda item number your question refers to.

Please note: No photography or recording without permission and please switch all

electronic devices to silent mode whilst in the meeting.

Getting here by foot Oxford House is a 5 minute walk from Bethnal Green Tube Station (Central Line) and is located just off Bethnal Green Road (A1209) on Derbyshire Street.

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mailto:[email protected];%[email protected]?subject=Question%20for%20the%20next%20Governing%20Body

Chair’s and Chief Officer’s Report

1 Purpose

The Chair’s and Chief Officer’s report will highlight items of interest to Governing Body members and the public. The Governing Body is invited to note this report and pursue any points of clarification or interest.

2 Chair’s report 2.1 Tower Hamlets Clinical Commissioning Group has been named ‘CCG of

the Year’ at the Health Service Journal Awards

Tower Hamlets Clinical Commissioning Group has been named CCG of the year at the Health Service Journal awards.

The award recognises “healthcare excellence and innovation” across the UK. Health secretary Jeremy Hunt addressed the audience, saying that the NHS is “the most patient-focused and patient-centred healthcare service in the world”.

Tower Hamlets beat more than 200 other CCGs across the country to receive the award. A judging panel made up of senior figures in the health service, including Jane Cummings, chief nurse of NHS England and Ciaran Devane, chief executive of Macmillan Cancer Support, decided upon the recipient.

Tower Hamlets CCG was praised for displaying “strong leadership, especially around clinical leadership, whilst retaining patient focus”.

2.2 Open Doors Education Team Winner of Health Education North Central And East London (HE NCEL) Quality Award

The Tower Hamlets HCA Development Programme has won 1st prize, in their category ‘Excellence in widening participation and wider workforce development.’ The award last night at Senate House won the ‘’Open Doors’ team a HENCEL bursary of £10,000 to be used by the team for education, conference attendance or equipment. The programme has been designed and developed by the Open Doors team, who are part of the Transformation team at the CCG and work under the umbrella of the Tower Hamlets Community Education Provider Network (CEPN.) Anne Morton and Diane Gould, who have managed and led the programme since April 2013, have been responsible for designing and delivering the clinical sessions. Six study days cover all the subjects vital for HCAs working in General Practice, including consultation

Enclosure A

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skills, the medico- legal aspects of their work, training for relevant roles e.g. undertaking NHS Health Checks, protecting confidentiality, promoting positive behaviour change via motivational interviewing, and much more!

The Diploma in Health and Social Care training is delivered by a facilitator from the Open University who assists staff with their portfolio development and is on hand to deliver one to one and group teaching during 6 of the 12 study days. To ensure that the learning is embedded in safe practice the mentors visit each participant 3 times over the 6 months of the course, and the OU assessor visits twice.

The funding for this programme has been provided by HE NECL via a grant, which has opened up the opportunities for HCAs in General Practice, a group that in many areas are ignored in terms of their professional development.

2.3 GPs boost COPD care through practice networks

GP practices in a London borough achieved marked improvements in measures of care for patients with COPD by linking together in networks, research has found.

The study - published in NPJ Primary Care Respiratory Medicine - showed practices in Tower Hamlets managed to increase the number of patients on the COPD register through a range of initiatives, such as calling in smokers within target age groups for spirometry, reviewing asthma diagnoses among persistent smokers and giving new patients brief questionnaires on COPD, by more than 20% over three years.

The project involved eight networks of four to five practices each (population size 25 to 40,000 patients) across the borough getting together to collectively deliver a care package for COPD. The aim was to achieve measurable changes in clinically important indicators of COPD management between 2010 and 2013.

In addition to increasing the COPD registered population, the networks increased the proportion of patients with COPD with a completed annual review, from 53% to 87%, and the proportion of patients referred for pulmonary rehabilitation, which rose from 45% to 70%.

The study authors, led by Dr Sally Hull at Queen Mary University London, concluded: ‘Improvements in COPD primary care in a socially deprived, ethnically diverse locality were observed over a 3-year period following financial and organisational investment into general practice networks.’

A similar approach in the same borough has also led to big improvements in cardiovascular disease prevention measures, in particular the proportion of patients with atrial fibrillation receiving appropriate anticoagulation treatment.

2.4 Barts Heart Centre Event, Thursday 5 February 2015

A Barts Heart Centre (BHC) event will take place on Thursday 5 February from 4-7pm at St. Bartholomew’s Hospital. The event will enable commissioner, primary care and secondary care colleagues to explore in more detail our plans for the Barts Heart Centre. The agenda for the event is:

• The strategic context for the new centre

• The draft service model, including opportunities to ensure good, local practice is preserved

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• Our plans to safely manage the move of existing services into the new centre

• Developing our education programme for students, colleagues and partners.

You can register for the event by contacting the Barts Heart Centre PMO ([email protected]) with your name, organisation and role.

2.5 Introducing the Community Paediatric Continence service Tower Hamlets CCG have commissioned Barts Health to deliver a new service to support children and young people with bed-wetting, constipation and long-term continence problems. The Paediatric Continence Service offers advice, assessment, treatment and management of bladder and bowel dysfunction to all children and young people from 4-19 years

2.6 Introducing ‘In the Know’ – Improving Access to Local Information About Mental Health Services

On 9 December 2014, THCCG and London Borough of Tower Hamlets launched 'In The Know' - an online directory of local mental health services in Tower Hamlets.

In the Know is an online directory of local mental health services for Tower Hamlets residents, health and social care professionals and local service providers. Residents can use it to search for services for themselves, their families or their friends. Health professionals can use it to find services on behalf of their patients. Service providers can do this too, and they can also promote their services through the directory There are approximately 30,000 adults estimated to have symptoms of a common mental health problem in our borough. Around 15,900 people are known to their GP to have depression, 3,300 known to have a serious mental illness, and there are around 1,150 older adults with dementia. In the Know will help build resilience of Tower Hamlets residents to common mental health conditions and promote wellbeing by providing accessible, accurate information about local mental health services. http://www.intheknow.ideastoreonlinedirectory.org/

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http://www.intheknow.ideastoreonlinedirectory.org/

3 Chief Officer’s report

3.1 CEO of NHSE Visits THCCG

Simon Stevens (CEO of NHS England) visited the CCG on Weds 7th Jan at Jubilee Street Practice. The meeting was split into two halves, one half focussing on the CCG’s successes and challenges and the other half focussing on the funding issues for Primary Care. The meeting was well attended from all parties and a good open discussion took place on all areas. The CCG presented our achievements and how they aligned themselves to NHS England’s 5 year plan which was well received.

Virginia Patania (Practice Manager Representative on the Governing Body) presented the latest data highlighting the financial challenges facing Tower Hamlets practices resulting from the changes in Primary Care funding allocations.

Kambiz Boomla (CEG and CCG IT and Informatics Clinical Lead) presented data on allocation of funding formulas for primary care. Recent policy on formulas has moved away from awarding additional funds to areas with high deprivation towards areas with an older population under the understanding that over 65s utilise more resources. Kambiz showed data that demonstrated that utilisation actually increases based on the complexity of the mix of patients and in the last few years of their life (regardless of what age your last years are).

3.2 CCG Chair gets New Year honour

Dr Sam Everington, chair of Tower Hamlets CCG has received a knighthood in the New Year's Honours. The award is for services to primary care and recognises the work Dr Everington has done over the last 20 years as a GP in Tower Hamlets to improve the lives of thousands of local people in one of the poorest boroughs in England and for his work in helping to shape the future of the NHS

3.3 Winter Pressures

The NHS is facing severe winter pressures. Locally Barts Health is struggling at all sites. The London Ambulance Service is also under a great deal of pressure due to increased activity.

The CCG is providing regular reports to NHS England on pressures in the system and what actions we are taking to manage these pressures. We are having regular conference calls with all key partners to support discharge from hospital. With winter pressure funding we have plans and schemes in place to support admission avoidance and discharge from acute hospital beds

3.4 Intelligent Monitoring of General Practice

In November 2014 the CQC published intelligent monitoring reports for general practices. The intelligent monitoring looks at a range of indicators to create priority bands for inspection. The CQC use the information to ask questions about the quality of care offered by NHS GP practices, but they do not use them in isolation to make final judgments. This is because there are various factors that require consideration when interpreting the intelligent monitoring banding a GP practice may currently be in. The intelligent monitoring is part of the CQC’s wider approach, including meeting with NHS England area teams and CCGs in advance of an inspection to understand the local context.

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3.5 Sir Sam Everington appointed to support local NHS in developing new Forward View care models NHS England, Monitor and TDA on behalf of the six national NHS bodies who led the development of the NHS Five Year Forward View this week appointed Sir Sam Everington to support implementation of the new care models identified in the Forward View alongside the Chief Executive of Watford, St Albans and Hemel Hempstead Hospitals. .

Sam will help lead national work on primary care-driven care models and service redesign

3.6 Governing Body Away Day

The Governing Body met on December 2 2014 for an away day. This day provided the space for the Governing Body to stand back and think corporately to define their vision and priorities for the coming 3 years to ensure that their focus truly makes a difference for their patients.

The following areas were identified as focal points for strategic development:

1. Supporting greater uptake of technology and information

2. Children’s strategy

3. Developing mental health provision, offer and support in primary care

4. Primary care development

5. Personalisation

6. Provider development

It was agreed that the CCG would identify a partner organisation to examine a case for change on these areas and the cost would not exceed £2million.

3.7 Governing Body Lay Member, Nurse Representative and Secondary Care Consultant Representative Term of Office Extension

Tower Hamlets CCG has extended the term of office for an additional 2 years for the Governing Body Lay Member, Nurse Representative and Secondary Care Consultant Representative. This is in line with our Constitution.

3.8 Freedom of Information Act Requests

For the period 1st October to 31st December 2014, a total of 62 FOI requests were closed for the CCG. In previous months, fewer FOIs were closed for the CCG compared to other WELC CCGs. However this difference has now disappeared.

During this period, 95% of requests were closed within the statutory 20 working days. The agreed target for NEL CSU is to achieve 90% or above.

The majority of requests have come from private companies, individuals and the media.

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The nature of the requests have been very varied, for example covering service restrictions, medicine management, CCG remuneration, tender documentation and governing body details.

End

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Minutes of the NHS Tower Hamlets Clinical Commissioning Group Governing Body Meeting (Part 1)

Tuesday, 04 November 2014, 14.30 – 16.45 Room MP701, 7th Floor, Mulberry Place, 5 Clove Crescent, London E14 2BG

1 General Business

1.1 Welcome, introductions and apologies

1.1.1 Present

Name Role Organisation Dr Sam Everington Chair – LAP 6 representative – Bromley By Bow Practice NHS THCCG Catherine Boyle Vice Chair - Lay Member (Patient and Public

Engagement) NHS THCCG

Dr Judith Littlejohns LAP 1 representative – The Mission Practice NHS THCCG Dr Haroon Rashid LAP 2 representative – Albion Practice NHS THCCG Dr Martha Leigh LAP 4 representative – Wapping Practice NHS THCCG Dr Osman Bhatti LAP 7 representative – Chrisp Street Practice NHS THCCG Dr Shah Ali LAP 8 representative – Barkantine Practice NHS THCCG Katherine Gerrans Practice Nurse representative NHS THCCG Dr Tan Vandal Secondary Care Specialist Doctor NHS THCCG John Wardell Deputy Chief Officer NHS THCCG Henry Black Chief Finance Officer NHS THCCG Dr Victoria Tzortziou-Brown

LAP 3 representative - Principal Clinical Lead – All Saints Practice NHS THCCG

Mariette Davis Lay Member (Governance) NHS THCCG Virginia Patania Practice Manager representative NHS THCCG Dr Isabel Hodkinson LAP 5 representative - Principal Clinical Lead - The

Tredegar Practice NHS THCCG

1.1.2 In attendance

Name Role Organisation Archna Mathur Director of Quality and Performance NHS THCCG Justin Phillips Governance and Risk Manager NHS THCCG Shuma Begum Business Manager NHS THCCG Charlotte Fry Commissioning Support Director NEL CSU Huw Wilson-Jones Deputy Director of Contracts NEL CSU Lee Walker Senior Contracts Manager NEL CSU Neil Kennett-Brown Programme Director – Transformational Change NEL CSU Paul Iggulden Associate Director of Public Health LBTH Judith Shankleman Public Health Senior Strategist LBTH Dr Tania Anastasiadis Tower Hamlets GP Cancer Lead St Stephen’s

Health Centre

Enclosure B

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1.1.3 Apologies

Name Role Organisation Jane Milligan Chief Officer NHS THCCG Maggie Buckell Registered Nurse NHS THCCG Dr Osman Bhatti LAP 7 representative – Chrisp Street Practice NHS THCCG Dr Somen Banerjee Interim Director of Public Health LBTH Robert McCulloch-Graham

Corporate Director LBTH

1.1.4 Welcome

Dr Sam Everington welcomed members and attendees to the Governing Body. Apologies received from Jane Milligan (Chief Officer), Maggie Buckell (Registered Nurse), Dr Osman Bhatti (LAP 7 rep), Dr Somen Banerjee (Director of Public Health) and Robert McCulloch-Graham (LBTH Corporate Director).

1.2 Declarations of Interest

The Chair asked Members for any declarations of interest. No new declarations of interest were noted for Part I of the meeting.

The complete register of interests is published on the NHS Tower Hamlets Clinical Commissioning Group’s website: http://www.towerhamletsccg.nhs.uk/about/conflict-of-interest-register.htm

1.3 Chair’s report

Dr Sam Everington presented the Chair’s report. The following highlights were reported:

- London Health Commission - Better Health for London

- NHS - Five Year Forward View

- Tower Hamlets CCG – HSJ nomination for CCG of the Year Award. HSJ visit to CCG Friday 31st October 2014, feedback very positive.

- The Chair also discussed the recent article in the Daily Mail which ranked Tower Hamlets CCG as the lowest for Diabetes Care based on a PHE Healthy Lives On-line tool, but PHE has now removed its data following objections raised by the CCG. Dr Sam Everington explained that only one GP practice in Tower Hamlets filled in the return, so the stats were completely invalid because they only represented one out of 36 practices, which is not a fair system to base the performance of the borough.

Members noted the Chair’s report.

1.4 Chief Officer’s report

John Wardell (Deputy Chief Officer) presented the item. The following highlights were reported:

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- Tower Hamlets CCG Shortlisted for the Clinical Commissioning Group of the Year and Improving Care with Technology Categories in the 2014 Health Service Journal (HSJ) Awards NHS England assurance process 13/14

- The Barts Health Joint Quality Conversation

- The 2014 National Cancer Patient Survey Results

- Legislative Reform Order (LRO)

Members noted the Chief Officers report.

1.5 Member’s Story

Sam Everington introduced the CCG Membership Story Video: Discussion on Cancer Services - Dr Tania Anastasiadis, Tower Hamlets GP Cancer Lead, Dr Sella Shanmugadasan – Harley Grove Medical Centre, Dr Sangeeta Rana-Masson – Merchant Street Practice.

Themes from the discussion are highlighted below:

- Variable quality of cancer services across the trust; there are good examples but also examples of poor practice.

- London-wide standards are in place and providers should be questioned when treatment falls below standards.

- Ongoing problems with information transfer.

- Some occasions where patient leaves initial appointment expecting follow-up appointment by phone or letter which doesn’t happen resulting in a GP re-referral which causes additional unnecessary delays.

- An audit carried out at one GP practice of all cancer patients in one year demonstrated huge variability with communication received from 2 week wait appointment and when trust informs practice that a patient has been diagnosed; on average 20-30 days for communication regarding diagnosis.

- Slow communication process overall, not keeping up with patient’s progress.

- Holistic needs assessments not being shared with GPs.

- GPs want faxed letters after patient leaves clinic highlighting what patient has been informed / investigation outcomes / treatment plan.

- There is a sense that there are managerial problems across services; how referrals are received, processed and followed up and patient’s being sent away after initial appointment without confirmed follow up appointment resulting in ‘lost patients’.

- The usefulness of a 2 week wait appointment where a follow up appointment for diagnostics was questioned; one stop clinics work better where investigations, results and treatment plans take place.

- Experience of poor communication between radiology and clinical departments.

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- There is a need for more/better benchmark trust data for patients to make informed choices of preferred trust for referral.

- There needs to be a review of GP access to diagnostic reports, quality of reports and timeliness of reports.

- There are ongoing issues around education. Currently Public Health funding early detection training for GPs and other clinical staff and Macmillan funding GP update course.

- There needs to be a WELc approach to cancer services around how we redesign service models and how we learn from each other.

- GPs are receiving staging information which allows practice reflection on levels of early and late referrals.

After the video there was a discussion where the following points were raised:

- Need for communication to be 24 hours not 3 weeks.

- Option of using other routes of communication instead of fax or post such as e-mailing to nhs.net. Current project taking place to trial e-mail direct to GPs.

- Concerns highlighted in member’s story are reflected in performance data.

- The Governing Body felt it would be useful for Mr Ajit Abraham (Surgery and Cancer CAG Group Director, Barts Health) and Sir Stephen O’Brien (Chair – Barts Health NHS Trust) to see the member’s story video.

Action: Forward member’s story to Mr Ajit Abraham and Sir Stephen O’Brien

1.6 Minutes and matters arising of the meeting held July 2nd 2014

1.6.1 Minutes

There were no requested amendments of the previous minutes. The minutes were approved as an accurate record of the meeting.

1.6.2 Matters arising

No matters arising and all actions completed.

2 Performance and Operations

2.1 Board Assurance Framework (BAF)

John Wardell presented the Board Assurance Framework and informed members that the framework had been refreshed, he highlighted the following key risks:-

Risk 1.1 – Systems and processes to monitor, challenge and support provider delivery of NHS Constitution target - Escalation of risk rating based on collective views across the collaborative and other stakeholders re: escalation quality and performance risks at Barts Health.

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Based on the escalating quality and performance risks at Barts Health the Tower Hamlets Governing Body Members expressed the need for a Board to Board meeting with Barts Health to seek appropriate assurances. It was thought this would work best with external facilitation.

Action: Archna Mathur is establishing process for arranging a Board to Board meeting.

Risk 1.2 – Designated Doctor and Nurse for Looked After Children (LAC) recruitment - the interim cover for the Safeguarding (LAC) nurse post has been identified, the substantive post remains vacant. Designated doctor for LAC (Dr Owen Hanmer) will be leaving post – BH will appoint interim.

The internal auditors have completed their review of the BAF, the Audit Committee and Senior Management agreed with the recommendations set out on the IA report; all recommendations to be implemented by November 28th 2014.

Members noted the item.

2.2 TH CCG Objective Scorecard

John Wardell presented the objective scorecard. Key area to note:-

- The majority of metrics have been rated as green with the exception of cancer two week wait (Red). There are several grey areas where data to support the metric is not currently available.

Key updates for November are:

- Achievement of Cancer 2 week wait continues to be Red. However performance has improved and unvalidated data for September suggests further improvements than the reported 85.8% compliance

- Integrated Care Dashboard showing admissions and readmissions for the IC target population reducing month on month since introduction of teams in October 2013. Indicator changed to Green.

- A&E activity continues to be less than planned

- Access to IAPT whilst 7 patients behind target is still forecast to over achieve against target- Green.

It was pointed out that overall there was a positive picture excluding the Cancer two week wait metric.


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2.3 Finance and Activity

2.3.1 Finance report month 6

Henry Black explained going forward the finance and activity reports are being updated to reduce duplication. He presented the finance report and also highlighted emerging risks:

- At month 6 the CCG is reporting a year to date surplus of £5.9m and forecast surplus of £11.9m, in line with the Financial Plan. However, commissioning reserves are required to offset pressures on contract activity, particularly in the acute sector and continuing health care area, in order to achieve the targeted position. Current projections suggest a possible worst case scenario of £7.5 - 8m Barts Health over-performance. Sufficient reserves are in place to cover this and ensure that the planned surplus is delivered.

- The contracting team are engaging with counterparts from Barts Health to finalise the 13/14 position. As in any year with a PbR contract, the agreed year-end balance reflected in our final accounts was based on M10 freeze data, M11 flex data and an estimate for M12. In addition it included a total value of challenges of around £10m. This means that the final settlement may potentially be marginally higher or lower than the total value reported in our accounts. At the time of writing the contract challenges process indicates that we are due a rebate in the region of £1-2m, however this has not been agreed by Barts and until agreement is reached this is not secure.

- Contract Query Notice (CQN) – Barts Health: In accordance with the contract, commissioners met with representatives of Barts Health and agreed a Remedial Action Plan (RAP) to remedy the breaches, with a number of key actions and milestones. The consequences set out in the contract of failure to agree the RAP, or failure to achieve any of the milestones contained within the RAP, are that commissioners shall withhold 1% of contract value per month for up to 6 months, with those funds retained permanently if the remedy is not actioned satisfactorily by the end of that period.

- Contractual Penalties – Barts Health: Barts Health has suffered from particularly severe problems in delivering the national requirements, and as a result the fines levied through the contract are high, possibly up to £4m for THCCG and £20m as a whole across all 12 associates to the contract. Barts has a planned financial deficit in the region of £43m but is reporting significant risk that the final outturn position will be substantially worse than this. By imposing the contractual fines, THCCG needs to balance the benefits of applying contractual measures designed to penalise poor clinical care with the obvious impact on the Trust’s finances, and the potential adverse consequential impact on its operational capacity. In light of this, CCG executives are discussing with the Trust how a jointly agreed plan may be agreed, to be resourced through reinvestment of the fines, which will deliver the quality improvements required. Approval of any reinvestment would be subject to Barts meeting a satisfactory trajectory of improvement.

2.3.2 Activity Report

Huw Wilson Jones presented the report. The following highlights were reported:

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• YTD Position: £5,928k surplus, with a forecast outturn position: £11,855k surplus. However, this includes significant budget pressures mainly on acute contracts.

• Main drivers for YTD budget variances:

• Barts £4,036k overspend.

• Guys £319k overspend.

• Mental Health Services £72k underspend but expected to be in line with contract offer.

• Other Non-Acute – Continuing Healthcare Net Position £275k overspend partially offset by learning difficulties with a £176k underspend.

• Prescribing is reporting a breakeven position.

• Reserves have been utilised to ensure the agreed YTD surplus of £5.9m is maintained.

The following items were raised in discussion:

Acute Contracts

The total Acute budget is £159.8m. At Month 6 the Acute position is currently showing a year to date overspend position of £5m with a full year projected overspend of £10.1m against plan.

- Barts Health – position at month 6, the year to date over performance is £4m, with a projected full year over performance position of £7.5m - 8m.

- Inpatient Non Elective – over performance in this area relates predominately to respiratory conditions. However this area had a large reduction in plan due to integrated care QIPP, this large variance would suggest that it is not being achieved, this will be investigated further in month 7.

- Outpatients – over performance in this area specifically relate to outpatient procedures and follow-ups. There has been a significant amount of Allied Health Professional activity which is contrary to the agreed contract, where it had been agreed that Allied Health Professional activity would apply to outpatient attendances. This has been included within the Contract Query Notice to the Trust.

- Other – This relates to a number of areas that do not fit into the categorised point of delivery sections such as HEMS, Patient Transport, direct access and high costs treatments. The biggest over performance in this area relates to HEMS and is largely attributable to the Trust charging all activity to Tower Hamlets as the host instead of recharging the other CCG’s, this too is within the Contract Query Notice.

- Critical Care – It is unclear what the reasons for over performance in this area, therefore this has also been included within the Contract Query Notice, in order for the Trust to advise the reason for the increase. The CSU has recommended that an

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audit should be carried out to establish the cause, as well as find out whether there is any activity which should otherwise be charged to NHSE.

- Financial Adjustments – this includes all expected adjustments expected by the end of the year these include; Emergency Readmissions, Productivity metrics and claims.

- Guys and St Thomas’s - At month 6, Guy’s and St Thomas’s position shows a year to date over performance of £319k, with a projected full year over performance position of £639k. This includes an RTT adjustment to the overall position of £288k.

- Homerton - At month 6, the Homerton position shows a year to date over performance of £244k, with a projected full year over performance position of £488k. This includes an RTT adjustment to the overall position of £145k.

Heathcare Provision

The total Healthcare Provision budget is £146.7m. At Month 6 the Healthcare Financial Position is currently showing a year to date overspend position of £20k with a full year projected overspend of £131k against plan.

Corporate Costs

For this financial year the CCG’s running costs allowance is £6.766m. As at month 6 the CCG is within plan to spend within its running cost Allocation. However, the overall corporate financial positon is overspent by £504k. This relates mainly to additional CSU costs outside of the core costs which had not been budgeted.

QIPP

The Tower Hamlets QIPP plan for 2014/15 has a total gross value of £11.8m, with a net QIPP savings of £6.2m.

After the papers were presented, the following points were discussed:

- Tracking down over performance of AHP was an important piece of work.

- We need to determine net value for over performance and reference with other providers with understanding of any gaps.

- Issues relating to AHP over performance may result in an arbitration process although we need to be clear about root cause before any interventions and it would be best to audit soon to move forward with any contract disagreements.

- Further clarification was sought relating to the £504k over budget corporate costs which related to unbudgeted CSU charges. Henry Black explained that there was a piece of work looking into a possible error in charging.

- Members discussed the issues of proper coding and verifying attributable costs with the possibility of calculating the costs to both the CCG and Barts Health re: amount of time spent on data issues.

- Data quality was an action point of Barts Health CQN RAP – although this was yet to be finalised by the relevant CFO’s.

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- It was felt more conversations with clinic peers was necessary to address the coding and data issues.

- Members discussed possible options for driving improvement with Barts Health coding and data issues; applying more budgetary restraints to lead clinicians in CAGs with budgets partly based on coding, data etc; requesting a dashboard around coding and developing a WELc wide informatics strategy ‘do it once and do it well’.

2.4 Performance and Quality report

Archna Mathur presented the item. The key areas to note were:

Serious Untoward Incidents/Never Events

Positive story - Barts Health has ZERO overdue SIs for September compared to 36 in August. The Trust process to manage serious incidents was part of the CQN (Contract Query Notice) issued to Barts Health with very close support from the CCGs. The focus is now on sustainability

Cancer

July data for the 2WW (2 week wait) suspected cancer standard is demonstrating underperformance against the 93% standard at Trust level with 90% and 89% at RLH (Royal London Hospital) however an improvement on the June position. There is a similar pattern of improvement for the breast symptomatic target with performance at Trust level at 93.2% and 96% at RLH hence achieving the target.

31 day targets to 1st treatment are being met at Trust level with 98.7.9% and 31 day subsequent surgery and drug treatment have been met for July with 100%.

62 day GP referral performance remains challenging with July data showing underperformance against the 85% target of 83.2% at Trust level.

• The Barts Health response to the Contract Query Notice (CQN) issued by commissioners, outlined recovery timescales as August 2014 for the 2ww performance (unvalidated August data is however showing that this trajectory has not been achieved with performance at 92%), and October 2014 for the 62 Day performance (data available in December). Unvalidated August data is showing an improvement for the challenged Head and Neck speciality however, achieving 97.1% compared to 73.2% for July.

The immediate focus for each speciality is to reduce capacity breaches so that any breaches remaining are only due to patient choice, where patients have been given appropriate time to accept an appointment date. Each speciality has been requested to provide analysis of when in the 14 day pathway appointments have been offered, to decrease choice breaches as this should be by day 7.

RTT

Barts Health continues to underperform against the national waiting time standards at speciality and Trust aggregate level. Recovery plans have been put in place but have been unsuccessful at delivering the results required in expected timescales. The Barts Health Director of Delivery and Improvement has commissioned an investigative review. The Trust

19

has 183 patients waiting over 52 weeks as at the end of September. NHSE has approved £7.3m resilience monies to support Barts Health RTT delivery.

A&E

Barts Health has failed to achieve the Q2 all types 95% standard by 0.18% with a performance of 94.82%. Performance is also below trajectory for Q3 to date particularly at RLH and Whipps Cross sites. The RLH has a LOS (Length of Stay) of 5.13 days, above the target 5 days, a variance of 2.6%. Bed Occupancy is 0.13% above the target 93% at 96%. Attendances at the RLH are in with 2013 attendance figures, but are up 7.9% against plan, with adult admissions also above plan by 2.1%. Breaches at RLH are due to bed availability, waits for specialist opinion in the ED (Emergency Department) and A&E assessment. Delayed discharges are affecting bed availability at the RLH due to delays in accessing specialist (tertiary) rehabilitation beds, repatriation of patients, continuing care cases, including a need to identify suitable nursing home placements and disputes. A second tranche of winter resilience funding has been allocated for which schemes are being worked up focussing on the need to reduce bed occupancy.

CQC

CQC have advised that they will be undertaking an inspection of the Whipps Cross site in early November. The Trust is preparing via the peer review process.

Joint Quality Conversation Event

The collaborative CCGs, led by Tower Hamlets CCG, organised a joint event with Barts Health, inviting all stakeholders to take stock of progress and quality and performance challenges following the CQC inspection in November 2013. The meeting has followed up by a further cross organisational meeting to discuss quality concerns and the outcome of this will be shared at the January Governing Body.

Quality Assurance Action Log

Since the September GB (Governing Body), Quality Assurance visits have been undertaken at the Ambrose King Centre (themed safeguarding children’s visit), ward 13E (Cardiology and respiratory) and ward 13F at the RLH (Respiratory, immunity and infection). A recurrent theme is the challenge of maintaining adequate staffing.

Action: Quality Assurance Action Log Tracker to be forwarded to the Governing Body Members.


2.5 Cancer Discussion

Dr Sam Everington informed the Meeting that Mr Ajit Abraham (CAG Director – Surgery and Cancer CAG) would no longer be able to attend the meeting and that it would be useful for the Governing Body to use the agenda item to discuss current issues and possible actions. The following points were raised in discussion:

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- There are good examples of positive feedback on part of some pathways but we need to be asking trusts why there is not positive feedback on other parts of the pathways.

- We need to establish who we need to liaise with on relevant matters.

- Possible solution to develop a Cancer Strategy Group

- Direct to colonoscopy appointments take place at Whipps Cross but not at other sites. Evidenced based medicine – colonoscopy should take place at the end of initial appointment.

Action: Write to Clinical / Managerial lead at each site lead to request when direct to colonoscopy service will be available from their service.

- Members and attendees discussed holding a future Cancer Summit. Many members thought a Summit would be useful and a platform to bring the recent Cancer National Patient Survey. It was pointed out that the patient survey had already gone to two CQRMs.

- It was noted that there are perceived issues at the clinical, finance and board level.

- Attendees requested further clarification who has ownership of changing models of care. Archna Mathur explained that Ajit Abraham holds financial and clinical authority.

- It was noted that there are considerable coding and data issues and that additional clinical support is needed with these processes.

- Member’s discussed the recent Patient Survey with Barts Health lowest in the country for patient experience. The Governing Body would like to know what has been implemented and how is improvement to be measured?

- There is a need for more benchmark trust data for patients to make informed choices of preferred trust for referral; data that would aid in driving earlier detection and data that would breakdown which departments are doing well or not.

- It was thought that it is currently difficult to get up to date validated data which is easy to cross reference. There are a lot of data sets from different sources that are not always easy to triangulate.

- Cate Boyle discussed the possibility of offering a bursary for someone to triangulate data; explaining there was a lot of data held at various charities such as Macmillan. It was felt that there is a lot of data available but not in a useful format.

2.6 London Ambulance Service Update

Lee Walker presented the report: London Ambulance Service, Performance Update Nov 2014. The following points were highlighted:

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- The London Ambulance Service has not met performance targets for the response times for Red 1 and Red 2 calls during 2014/15 and LAS are not expected to recover the position by the end of the year.

- LAS performance declined sharply in April 2014.

- An underlying cause of the poor performance is a shortage of Paramedics in London linked to high turnover of staff at LAS.

- Actions are being taken on a pan-London basis to tackle the problem. This work is being coordinated by the lead CCG commissioner working closely with NHS England and the NTDA. Action is also being taken by local CCGs.

- Performance in beginning to improve and LAS are making plans for turnaround work to continue into 2015/16 primarily aimed at tacking Paramedic retention.

- A formal contractual improvement process has been commenced and LAS are currently in turnaround.

- There is potential for poor performance to impact on the LAS ability to respond to emergencies and major incidents. There is also the risk that patients with lower acuity conditions will have to wait much longer for an ambulance.

- It is important that Ambulance Service performance is monitored closely and that remedial action plans are implemented so that performance is improved as quickly as possible.

- Performance management of LAS is being led by the lead commissioner, Brent CCG.

- Tower Hamlets CCG should also continue to monitor performance and review commissioning decisions to ensure that demand upon the Emergency Ambulance service is not increased.

After the presentation there was a discussion where the following points were raised:

- Members queried if call handlers were referring appropriately and how 111 service was impacting on service. The members were assured that these issues were being picked up holistically by the urgent care working group.

- Cate Boyle thanked Lee Walker for a clear presentation stating she felt assured as board member that what could be done is currently being done.

Dr Sam Everington presented a letter for approval re: London Ambulance Service, support for return to ‘Key Worker Help to Buy’ schemes to improve paramedic staffing levels in London.

The letter was approved by the Governing Body to send to Mayor Boris Johnson and it was also agreed that the letter should also be sent to the local Mayor Lutfur Rahman.

Action: Send London Ambulance Service Letter to Mayor Boris Johnson and Mayor Lutfur Rahman.

Break

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3 Commissioning and Strategy

3.1 Transforming Services, Changing Lives (TSCL) – Case for Change

Dr Sam Everington presented the paper – Transforming Services, Changing Lives – the Case for Change for approval. The following points were highlighted:

The Transforming Services, Changing Lives programme identifies a number of areas in which there is a Case for Change to secure high quality care in a sustainable way. Patients, residents and clinicians from across east London have made it clear that achieving these changes in hospital care will require the whole health and social care system (primary and community care, mental health, hospitals and social care) to come together, to work across organisational boundaries, in order to deliver lasting improvements for patients.

Eight areas of consensus are:

1. Our population is growing and the local NHS needs to respond to increased demand, for example in maternity and children’s services

2. Our population is ageing - with increasing numbers of people with long term conditions

3. We and our partners need to work together more closely to strengthen our prevention approaches, supporting people to live healthier lives and improving physical and mental wellbeing

4. The local NHS needs to invest time and effort in tackling inefficiencies. Estates, IT systems and care pathways sometimes do not work for the greatest benefit of patients or staff

5. We need to fix our urgent care system, ensuring patients are seen in the right care setting for their needs

6. We need a transformed workforce for 21st century care – with different skills and roles, working in different settings

7. Changes will need to be made to local services if they are to be safe and sustainable. More services need to be provided in the community, closer to home

8. The local NHS and partners will need to work together to secure high quality and financially sustainable services in east London.

The members and attendees raised the following points relating to the TSCL case for change:

- It was highlighted that this programme sits in the overarching Transforming Services Together programme and that at this stage the Governing Body were being asked to approve that the Case for Change appropriately and adequately sets out the current position and articulates current knowledge of future pressures on the health economy so that the programme could move on to the next stage.

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- The Case for Change was trying to form a multi-agency consensus – ie across CCGs, providers, Local Authority etc

- The quarter of a million plus predicted population growth across the collaborative boroughs represents a significant challenge but also an exciting opportunity for service redesign.

- The Case for Change has received positive feedback from the scrutiny committees.

- A significant opportunity for better joined up working with the beginnings of a vision of what change could look like across the pathways.

- Members were interested to know how the programme would overlap with academic opportunities.

- Workforce issues to deliver the programme were discussed and it was felt this is an area that would be looked into early in the programme development.

- The Case for Change was praised for being a really good paper with good rationale and that the change outlined was inevitable based on current and future pressures.

- It was confirmed that funding for the programme is a top slice across all partners.

- The paper represents a good sense of the health economy working together.

- The need to explore the principles of the engagement framework especially in relation to future service redesign was discussed.

- Cate Boyle informed the meeting that public engagement had been good so far but that it will become increasingly important when more difficult decisions will need to be made.

The members approved the Transforming Services, Changing Lives – Case for Change, with the following caveats:

- Academic programmes are an integral part of the programme design.

- The development of an engagement framework for making decisions.

- The reinforcement of programme enablers ie workforce, estates etc.

4 For information

4.1 Audit Committee Summary

Mariette Davis informed the meeting that since the inclusion of the Audit Committee Summary in the Governing Body papers another Audit Committee had taken place on November 3rd 2014, and the following points were to note:

- Audit Committee had reviewed the current procurement process and discussed the potential benefits of applying a value based system; where lower value contracts can be approved by the Senior Management Team with the higher value contracts approved at board level.

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- The Audit Committee had reviewed the Conflicts of Interest Policy and felt that the policy needed to be updated to reflect future changes in the commissioning landscape such as co-commissioning.

Action: Justin Phillips to update the Conflicts of Interest Policy in line with upcoming co-commissioning guidance


4.2 Finance, Performance and Quality Committee Summary

No further comments were raised. Members noted the item.

4.3 Locality Board Summary


4.4 Executive Committee Summary


4.5 Equality and Diversity Committee Summary

5 Questions from the public

No questions were raised.

6 Any other business

No additional items were raised by members.

End

25

Matters arising

Action reference Action Lead Due

Date Update

Nov#1 Forward member’s story to Mr Ajit Abraham and Sir Stephen O’Brien. JP Mar 2015

Suggestion to use as part of Board to Board meeting

Nov#2 Archna Mathur is establishing process for arranging a Board to Board meeting. AM March

2015 In progress

Nov#3 Quality Assurance Action Log Tracker to be forwarded to the Governing Body Members.

JP Nov 2014 Actioned

Nov#4

Write to Clinical / Managerial lead at each site to request when direct to colonoscopy service will be available from their service.

AM March 2015 Ongoing

Nov#5 Send London Ambulance Service Letter to Mayor Boris Johnson and Mayor Lutfur Rahman.

TP Nov 2014 Actioned

Nov#6 Conflicts of Interest Policy to by updated. JP 27/1/15 Actioned

26

Governing Body Meeting Enclosure

Date of meeting January 27 2015 C

Agenda item 2.1

Title of report: Board Assurance Framework

Author(s): Justin Phillips – Governance and Risk Manager – NHS Tower Hamlets CCG

Presented by: Sponsor (if different): For further information

Jane Milligan – Chief Officer - NHS Tower Hamlets CCG

[email protected]

Executive summary

The Board Assurance Framework lists the risks that could prevent the achievement of the CCG’s 5 Strategic Objectives.

There were no perceived changes to the risk ratings of any of the BAF risks at this iteration.

Update on risk positions:

Strategic Objective 1: High Quality health and social care services

1.1 Systems and processes to monitor, challenge and support provider delivery of NHS Constitution target

The recent CQC inspection at Whipps Cross Hospital has led to a decision by CQC to expedite inspections of the Royal London Hospital and Newham Hospital in January 2015. The CCG has requested that Barts Health NHS Trust review the CQC action plans from the November 2013 inspection and cross reference with findings from current Whipps Cross inspection, and identify and accelerate any outstanding actions relating to the Royal London. The “CQRM Plus” escalation meeting taking place in January 2015 will also serve to identify further risks and concerns and establish next steps across the commissioners of Barts Health.

As per previous Audit Committee recommendation, a medium priority action has been assigned: Establish THCCG – Barts Health, Board to Board meeting.

1.2 Designated Doctor and Nurse for Looked After Children (LAC) recruitment

Update on posts: Designated doctor post currently covered by Barts Health - Dr Monika Bajaj. Interview for replacement is January 8th 2015. There is a discussion with Newham CCG about the possibility of

27

a joint post for both CCGs and a timescale for this if it's likely.

1.3 Adult safeguarding

The Safeguarding Adults Board has commissioned a serious case review involving NHS providers to begin shortly and another to begin at a later date subject to police confirmation of action.

Adult Safeguarding Committee will review statutory guidance from the Care Act with view to ensure provider compliance.

3.10 Risks associated with commissioner split

Removed from this iteration of the BAF as per previous update - After consideration, the risk was deemed not to be current and it has been decided that the risk will be removed from the next version of the BAF. There is currently a discussion with the CFO to reinstate risk at next BAF iteration as Barts Health are billing CCG incorrectly for specialised services.

There were no significant changes to report for the remainder of the BAF risks.

Internal Audit

Internal Audit work in progress: BAF review phase II:

- Adverse position of Barts Health NHS Trust

- Contractual settlement with Barts Health NHS Trust

Recommendation

Information Approval To note Decision

The Board Assurance Framework is presented to the Governing Body to note the risks and make any comments on the risks within it.

Conflicts of Interest There are no declared interests affecting this report.

Key issues • The BAF is presented to Governing Body Members to provide oversight of risks to the achievement of the CCG Strategic Objectives.

• This assists Governing Body Members to identify and prioritise risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

• It is important that the Governing Body continue to make effective use of the BAF in 2014/15.

Report history This version of the BAF was reported to the Audit Committee on January 5 2015.

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Patient and Public involvement

The BAF is a public document and provides assurance to all external stakeholders.

Risk 4.1 relates to the current and proposed mechanisms for engagement with patients and public.

Link to the Board Assurance Framework

The BAF is an essential document in providing evidence of THCCG's system of internal control. It aims to provide the Chief Officer with sufficient assurance to be able to sign off the annual governance statement of the CCG at the end of the financial year.

Impact on Equality and Diversity

The CCG has selected E&D as a Strategic Objective:

Challenging discrimination and promoting equality both as an employer and a commissioner of health care services.

Resource requirements There are no additional resources required.

Next steps The next round of risk reviews will commence during February 2015.

The Audit Committee will receive and review the BAF at each of its meetings. It will choose significant risks, on a rotational basis and subject them to “deep dive” reviews of risks, controls and assurances to ensure that the controls and assurances as recorded on the BAF are operating in practice.

In this way the Audit Committee will look to provide assurance to the Governing Body that the BAF is valid and suitable for the Governing Body’s requirements.

29

Board Assurance Framework

2014/15

Document information

Version Version 6 Dates covered 25 October 2014- 24 December 2014 Next review February 2015 Author(s) Justin Phillips – Governance and Risk Manager

31

Contents

Key Performance Indicators ............................................................................................................. 3

Interpreting the 2014/15 BAF ........................................................................................................... 5

Risks to the Strategic Objectives ...................................................................................................... 6

High Quality Health and Social Care Services .............................................................................. 6

Integrated services to meet individual needs .............................................................................. 10

Creating a vibrant and stable social care system ........................................................................ 11

Support local people and stakeholders to have a greater influence on services we commission and develop a responsive and learning commissioning organisation .......................................... 20

Challenging discrimination and promoting equality both as an employer and a commissioner of health care services. ................................................................................................................... 22

Escalated from the CCG risk register ............................................................................................. 22

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Key Performance Indicators - Risk summary sheet - Table 1.

April June Aug Oct Dec

1.1

Failure to ensure effective systems and processes are in place to monitor, challenge and support provider delivery of NHS Constitution targets could result in increased likelihood of poor quality, poor patient experience and delivery of poor clinical outcomes.

20 9 12 16 16 8 12 8

1.2 The CCG does not have a Designated Nurse for Looked After Children;

16 6 6 4 4 3 3 3

1.3 Uncertainty over providers’ contractual compliance with Adult and Child safeguarding

16 6 12 4 4 4 4 4

2.1 Failure to deliver on the Operating Plan, including QIPP 25 12 12 12 12 6 12 12

3.1 Governing body, staff and members inadequately trained or have inadequate capacity to deliver on statutory functions.

9 3 3 3 3 3 3 3

3.2 Changes to Governing Body Leadership impacting delivery of several programme boards

10 3 3 3 3 3 3 3

3.3 Poor management of the CSU contract 16 9 9 3 3 3 9 9

Forecast Y5

Strategic Objective 1: High Quality health and social care services

Target Forecast Y2Risk # Risk Summary Trajectory

Strategic Objective 2: Integrated services to meet individual needs

Strategic Objective 3: Creating a vibrant and stable health and social care system

2014

33

3.4 Position of Barts Health NHS Trust 16 9 12 12 12 12 12 12

3.5 2014/15 Contractual Settlement with Barts Health 20 9 12 10 10 10 10 10

3.7 Specialised commissioning and CHC. 16 12 16 12 12 12 12 12

3.8 Risk of increased pressure on the Continuing Care budget. 16 12 12 12 12 12 12 12

3.9 Financial challenges of other WELC CCGs 16 9 12 12 12 4 4 4

4.1 Not maximising collaborative working and engagement 12 8 8 8 8 3 4 3

5.1 The risk that the services commissioned by the CCG do not meet the equality and diversity needs of the local population.

12 9 9 9 9 3 3 3

Strategic Objective 5: Challenging discrimination and promoting equality both as an employer and a commissioner of health care services.

34

Interpreting the 2014/15 BAF

35

Risks to the Strategic Objectives High Quality Health and Social Care Services

Systems and processes to monitor, challenge and support provider delivery of NHS Constitution targets Comment: The recent CQC inspection at Whipps Cross Hospital has led to a decision by CQC to expedite inspections of the Royal London Hospital and Newham Hospital in January 2015. The CCG has requested that Barts Health NHS Trust review the CQC action plans from the November 2013 inspection and cross reference with findings from current Whipps Cross inspection, and identify and accelerate any outstanding actions relating to the Royal London. The “CQRM Plus” escalation meeting taking place in January 2015 will also serve to identify further risks and concerns and establish next steps across the commissioners of Barts Health. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 1.1

Risk Description Controls Assurances GAPS Risk Ratings

Documentation Control Assurance Likelihood x Severity

Failure to ensure effective systems and processes are in place to monitor, challenge and support provider delivery of NHS Constitution targets could result in increased likelihood of poor quality, poor patient experience and delivery of poor clinical outcomes.

1-Monthly CQRMs discuss quality concerns with the providers to review and challenge improvement strategies, plans and trajectories. 2-Bi-weekly escalation meetings (level 4 of performance management framework) to focus on and facilitate improvement of specific quality and performance targets until sustainable delivery achieved. Meetings are attended by Senior managers of stakeholder CCGs and the NTDA. 3-Quality and performance of providers discussed at each Governing Body to ensure open culture of discussing risks and give the GB oversight of quality and performance (also reported via the CCG outcomes scorecard). 4-Monthly FPQ ensuring the CCG and CSU have the opportunity to discuss and review improvement strategies. 5-Monthly Strategic Performance review of the contract 6-Monthly quality leads meeting 7-CQN – Remedial action plan (RAP) review 8- Bi-weekly deep dives into each challenged cancer tumour groups to understand root causes of failure, and trajectories for improvement. 9-Dedicated review across WELCCGs of the Barts Health, CSU, CCG serious incidents (SI) process to expedite

1- CQRM minutes 2- Minutes of bi-weekly escalation meetings. 3- Governing Body minutes 4- FPQ minutes 5- SPR Minutes 6- Quality Leads Minutes 7- CQN + RAP 8-Minutes of cancer meetings 9-SI panel minutes 10- MSA audit tool 11-Letter to Barts Health re: CQC action plans 12-CIP review slide deck 13- Quality conversation write up 14- CQRM plus slide deck

- None identified at present

-None identified at present

Initial

5x4

+’ve Current 4x4 Date added 1-New performance management

process for Cancer 2-NHSE ‘Assured’ status for 2013/14 Delivery Dashboard for all domains except domain 3 ‘assured with support’ 3-Achievement of SI Remedial Action Plan

Forecast Y2

3x4

April 2014 Risk References -‘ve

Forecast Y5 2x4

Governing Body Lead NHS England Scorecard ref -None identified at present Target Date: 2017 2x4

Dr Sam Everington Domain 1, 2, 3 Trajectory Management Lead CCG Delivery Dashboard Archna Mathur –Director Quality and

NHSOF4, NHSOF5

See Table 1 36

Performance closure of overdue cases. 10- Mixed Sex Accommodation (MSA) Audit 11- Letter to Barts Health to request progress update on CQC action plan 12-Deep dive review into 12 sample CIP reviews 13- Quality conversation event 14- Cross organisational development 15- CQRM plus meeting 15.1.15 16-Attendance to the Quality Surveillance Group to share and gain intelligence on Barts Health with Healthwatch and fellow commissioners.

Lead Committee Governing Body agenda item ref Finance, Performance and Quality Committee

GB standing item 2.3: Performance and Quality report Delivery Dashboard

Actions HIGH priority (30 days) MEDIUM priority (30 – 90 days) LOW priority (90 days plus) - Follow up escalation meeting with trust executives and NEDs – cross organisational: NHS E and TDA. - Escalation meeting (CQRMplus) January 15 2015

-Whipps Cross CQC inspection follow up - Establish THCCG – Barts Health, Board to Board meeting


37

Designated Doctor and Nurse for Looked After Children (LAC) recruitment Comment: Update on posts: Designated doctor post currently covered by Barts Health - Dr Monika Bajaj. Interview for replacement is January 8th 2015. There is a discussion with Newham CCG about the possibility of a joint post for both CCGs and a timescale for this if it's likely.

Risk 1.2



Failure to recruit a substantive Designated Nurse for Looked After Children could result in reduced quality of services offered to looked after children, a failure to meet a condition of CCG authorisation and a recommendation from the joint CQC/Ofsted June 2012 inspection. Interim LAC designated doctor appointed by Barts Health posing possible risks of capacity, reduced quality of services and conflict of interests re: CCG’s quality assurance role.

1-CCG continued to employ Anne Morgan an independent consultant to carry out the work plan of the Designated Nurse for LAC on a rolling basis. 2-Monthly safeguarding Committee reviews safeguarding practice issues and outstanding actions. 3-Governing Body oversight of the situation 4-Governing Body received an annual report on LAC

1-Governance structure with LAC staff in post. 2-Agendas and minutes of Safeguarding Committee. 3&4- Annual report for LAC 3&4-Governing Body Minutes

-Substantive recruitment to the doctor and nurse LAC post.


Initial

4x4

+’ve Current 2x4 Date added -None identified at present Forecast

Y2 1x3


Forecast Y5 1x3

Governing Body Lead

NHS England Scorecard ref -None identified at present Target 2015 1x3

Maggie Buckell Domain 4 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Rob Mills NHSOF5 Lead Committee Governing Body agenda item ref Safeguarding sub Committee

None

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present -Archna Mathur, Rob Mills and Anne Morgan to meet to

review substantive nurse post and recruitment process. -Parallel recruitment process for Designated Doctor LAC post.


38

Adult safeguarding Comments: - The Safeguarding Adults Board has commissioned a serious case review involving NHS providers to begin shortly and another to begin at a later date subject to police confirmation of action. -Risk continues with smaller providers. Lead Committee comments: The Safeguarding Committee reviewed the BAF risk on 11.11.14 and it was agreed the current controls and assurances were adequate.

Risk 1.3



Uncertainty over providers’ contractual compliance with Adult safeguarding, Mental Capacity Act and implementation of the Care Act from April 2015would result in increased likelihood of avoidable to harm to vulnerable individuals.

1-There are clear Adult safeguarding roles at Barts Health NHS Trust and ELFT. 2-The CCG attends the Safeguarding Adults Board is a statutory partner 3- Director of Mental Health and Joint Commissioning and attends the Barts Safeguarding Committee. 4-Review of Safeguarding KPIs in main contracts and reviewed by CQRMs. 5-Bi-monthly safeguarding Committee reviews safeguarding practice issues and outstanding actions. 6-The Safeguarding annual report was presented to the September meeting of the Governing Body. 7-CCG staff uptake of Adult and Child Safeguarding training is monitored. 8- Completion of the SAB self-assessment process 9- Contractual process and training KPIs. 10. Mental Capacity Act.

1-Barts Health and ELFT Structure chart 2-Minutes 3-Contracting team performance reports. 4-Minutes of the Safeguarding sub-committee 5-Safeguarding annual report 6-CCG staff levels of safeguarding training and train all staff.

- Mental Capacity Act and Prevent compliance with some providers.


Initial

4x4

+’ve Current 1x4 Date added -None identified at present Forecast

Y2 1x4


Forecast Y5 1x4

Governing Body Lead

NHS England Scorecard ref -None identified at present Target 1x4

Dr Judith Littlejohns Domain 4 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Richard Fradgley NHSOF2 and NHSOF5 Comment Lead Committee Governing Body agenda item ref None Safeguarding sub Committee

None

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present - Review work – safeguarding adult audit.

- Adult safeguarding committee will review statutory guidance from the Care Act with view to ensure provider compliance.

-Embed the safeguarding training programme for 2014/15.

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Integrated services to meet individual needs

Delivery of the Operating Plan, including QIPP Comment: Actions: - There are no significant changes to report The provider productivity workstream (following arbitration judgement – this risk has been merged with 3.5) being agreed will result in an increased likelihood of achievement and reductions in cost. This will make it increasingly likely that the objective will be achieved at the end of Y2 and Y5. This has been added as the most important control measure for this risk. The 2 additional programme managers have been recruited to the transformation and innovation team, this was a gap in control on the last iteration of the BAF. A medium priority risk on the last BAF was to ensure that all the programme board risks are added to the central risk register. This has been completed. Lead Committee comments: TIC agreed to take assurance from current risk management approach – Nov 11 2014

Risk 2.1



Failure to deliver on the Operating Plan, including QIPP would result in:

• a negative financial impact on the CCG.

• Lost opportunity to produce and deliver increased outcomes for the sickest people in Tower Hamlets.

• A negative impact on the reputation of the CCG.

All QIPP schemes are more ambitious than previous years’ and linked to challenging areas.

1-Provider Productivity Programme is co-ordinated across WELC to ensure delivery at scale. 2-Plans are scrutinised and approved the TIC and Governing Body through a methodical process. 3-Very detailed HRGs exist for where the savings will be made. 4-Re-investment into services is determined by the return of savings e.g. Barts Health NHS Trust recruitment is based on savings. 5-QIPP programme management process 6-Monthly monitoring meetings to ensure programme boards are on track; off track programmes are discussed at the TIC. 7-All Programme Boards have a management and Governing Body lead with additional subject matter experts brought in as and when required.

2,3,4&5-TOR, minutes and agendas of the Programme Boards, TIC, FPQ and Governing Body. 3-HRGs

-Robust reporting of the Programme Board risk registers to the TIC. -Productivity process was done quicker than ideal following the arbitration decisions. CCG to work with CSU on more robust process in future.

-None identified at present.

Initial

5x5

+’ve Current 3x4 Date added -Monthly dashboard within the FPQ

papers is RAG rated and shows that the programs are delivering. -Budget remains on track -Outcomes monitored monthly and quarterly -Positive patient level data metrics.

Forecast Y2

3x4


Forecast Y5 3x4

Governing Body Lead NHS England Scorecard ref -None identified at present. Target 2x4 John Wardell Domains 1,3,5,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Josh Potter NHSOF1,2,3,4,5 Lead Committee Governing Body agenda item ref Transformation and Innovation Committee

-Standing items: Perf. and Quality report, Finance and Activity report -May GB: 5 Year Strategic Plan -July GB: Barts Health KPIs, 2013/14 Diabetes CQUIN,

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present. -None identified at present. -None identified at present.

40

Creating a vibrant and stable social care system

Organisational Development Comment: Current development work includes implementation of a talent management process and clinical leadership.

Risk 3.1

Risk Description Controls Assurances GAPS Risk Ratings Documentation Control Assurance Likelihood x Severity

Governing body, staff and members inadequately trained or have inadequate capacity to deliver on statutory functions.

1-Organisational strategy developed for staff, GB members, clinical leads which is inclusive of training needs analysis, induction, mandatory training and ‘Lunch and learn’ sessions. 2-CCG Constitution in place creating a structure for delivery of statutory functions. 3-CSU contracted to provide several statutory functions at scale. 4-Policy structure ensures policies clear identify any training, E&D and PPE requirements are. 5-ET and SMT oversight of OD delivery. 6- Management lead for OD identified within organisational structure. 7- Quarterly mandatory training update.

1-ACTUS HR management software implemented 1-Organisational development plan. 1-Staff PDPs. 1-Induction policy 1&2-Appraisals and objective setting 3-Staff training database inclusive of certification. 4-CCG Constitution and governance structure 3-SLA with CSU and documented meetings between CSU and CCG management teams. 5-ET and SMT action log and minutes 5-Agendas, papers and notes

-Implement a talent management process aspect of the OD strategy. -Development of Clinical Leadership. -CSU conduct training needs analysis on behalf of CCG


Initial

3x3

+’ve Current 1x3 Date added -Recruitment and retention rates are

good, -Low sickness absence rate -Positive feedback from staff in the barometer -Staff attendance at the Lunch and Learn sessions

Forecast Y2

1x3


Forecast Y5 1x3

Governing Body Lead

NHS England Scorecard ref -None identified at present. Target 1x3

Jane Milligan Domain 4 and 6 Trajectory

Management Lead CCG Delivery Dashboard See Table 1

Ellie Hobart None Comment

Lead Committee Governing Body agenda item ref None

Executive Team None Actions

HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present -Implement a talent management process aspect of the OD strategy

by 4 January 2015 - Development of Clinical Leadership

41

Changes to Governing Body leadership Comment: There are no significant changes to report No change to the risk rating as there were no actions to be completed. The handover from the 2013/14 Governing Body Members who stood down to the newly elected 2014/15 was successful. Lead Committee comments: TIC agreed to take assurance from current risk management approach – Nov 11 2014

Risk 3.2



Changes to Governing Body Leadership could negatively impact: Planned Care, Integrated Care, CHS and Prescribing programme boards through: a-loss of expertise b-break in continuity c-adversely affected relationships with other providers It also presents an opportunity for new ideas and a fresh perspective.

1-There is a process for handover which includes shadowing. 2-There is an engagement factor with programme development 3-Regular meetings with the Deputy Director of Commissioning and Transformation in place. 4-No change with the Clinical Leads 5-No changes to the TIC leadership 6-All plans are based on existing commissioning plans to ensure stability.

1-Documented handover and induction and OD programme for GB members 6-Operating Plan


-None identified at present. Initial 5x2

+’ve Current 1x3 Date added -Delivery of programmes and

workload. Forecast Y2 1x3

April 2012 Risk References -‘ve Forecast

Y5 1x3

Governing Body Lead


Jane Milligan Domain 4,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1

Josh Potter NHSOF1,2,3,4,5 Comment Lead Committee Governing Body agenda item ref In 5 years’ time there

will be significant upheaval in the clinical leadership of the CCG due to the rules of the constitution. This is why the Y5 forecast is higher than Y2.

Transformation and Innovation Committee

May GB: 5 Year Strategic Plan

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present -None identified at present -None identified at present.

42

Management of the CSU contract Comment: There are no significant changes to report. The internal auditors provided the CCG with a positive opinion of the CCGs management of the CSU contract. Recommendations arising from this audit recommend an increase in transparency in the sharing of information between the CCG and CSU.

Risk 3.3



Poor management or lack of direct statutory accountability of the CSU contract and the services provided could result in duplication of effort; poor value for money; lack of clarity over roles, loss of scrutiny and weakness in controls assurance and governance.

1-Level of CSU support agreed. 2-Open dialogue between CCG and CSU on amendments to the level of provision. 3-Monthly meeting with the Deputy Chief Officer, Director of Quality and Performance and the Commissioning -Support Director from the CSU. 4-Quarterly meeting between TH CO and CSU MD. 5-Escalation process for resolution of issues established. 6-Monthly performance management meetings have been set up between CSU and the CCG 7-All CCG staff are asked for their input. This ensures oversight of all performance aspects of the CSUs offer to the CCG. 8-Commissioning of CSU for 15/16 and beyond to be developed by SMT group with focus on in house, shared and external support requirements.

1-CSU Contract and Service Level Agreement 2-Comms records between the CCG and CSU. 3-Action logs 4-Action logs 5-Documented escalation process 6-Minutes 7-Email circulated to all staff, the feedback received and the minutes of the performance mgt. meeting.

-Develop and monitor KPIs for the CSU Contract. -Conduct an ‘In-house support workshop’.


Initial 4x4

+’ve Current 3x3 Date added -Internal Auditors positive Forecast Y2 3x3 April 2012

Risk References -‘ve Forecast Y5 3x3

Governing Body Lead

NHS England Scorecard ref -None identified at present.

Target 1x3 Jane Milligan Domain 4 Trajectory Management Lead

CCG Delivery Dashboard

See Table 1 John Wardell None Lead Committee Governing Body agenda item ref Executive Team

None

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present. -None identified at present. -Reflect on the recommendations arising from the internal

audit report

43

Adverse Financial Position of Barts Health NHS Trust Comment: No significant changes to report Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 3.4


The poor financial position of Barts Health NHS Trust creates a risk across the health economy.

(1) Rigorous process run by the CSU to challenge SLAM data inclusive of penalties and other contractual levers. (2) Finance Performance and Quality Committee review variance analysis against planned contracted activity levels allowing the CCG to address early signs of over performance. (3) Productivity metrics contained within the contract limit the volume of routine activity payable to clinically agreed levels, making better use of Trust capacity and CCG resources (4) POLCV identifies procedures deemed clinically inappropriate which the CCG will not fund, (5) Demand management schemes designed to reduce avoidable admissions or treat lower risk patients in a more appropriate setting (6) Activity management plan within the provider contract requires Barts Health to explain and justify any unplanned increases in activity over agreed tolerance levels.

(1)%age of challenges which are successful (3)TOR, minutes and agendas of the Finance, Performance and Quality Committee (3)Highlight reports from the FPQ to the Governing Body. (3)Monitoring reports demonstrating the effectiveness of demand management schemes. (4)Provider contracts held by the CCG. (5)Approved claims management process (7)Procedures of limited clinical value (POLCV) policy (8)Documented demand management scheme (9)Barts Health Activity management plan (1)Provider performance reports. (2)Audit report and TOR of scope of Barts Health internal review. (3)Remedial action reports from the Provider reviewed by the CCG (5)Approved claims management process (6)TOR and minutes of Commissioning NIS (9)activity management plan

Practice based commissioning (PBC) reporting

Practice based commissioning reports

Initial

4x4

+’ve Current 3x4 Date added -None identified at present Forecast Y2 3x4


Forecast Y5 3x4

Governing Body Lead


Henry Black Domain 4,5,6 Trajectory

Management Lead CCG Delivery Dashboard See Table 1

Henry Black None Lead Committee Governing Body agenda item ref FPQ Standing item 2.2.2 Finance and Activity

report

Actions

HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present Reinstate PBC reporting -None identified at present

44

Contractual Settlement with Barts Health Comment: No significant changes to report. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 3.5



(1) The arbitration panel ruling has resulted in a significant reduction in the value of the productivity metrics which can be applied to contractual activity. If the Trust fails to improve its levels of productivity this will result in higher levels of follow-ups which the CCG will be required to fund under PbR. This significantly reduces the CCG’s ability to deliver its QIPP target.

(2) The Trust has signalled the intention to invoice for non-PbR acute activity performed by Allied Health Professionals (AHPs) which is permissible under the terms of the guidance. This will be charged at a locally agreed price. This creates a risk not only of the cost of additional activity not previously charged but also that activity performed by the services funded through the block contract for CHS could be charged for twice.

(1.a.) The Barts health CCC is leading a programme of clinical work to underpin the revised metrics. This will include full briefing and guidance to the clinicians involved to ensure the outcome is as beneficial as possible for the CCG. It is intended that agreement be reached quickly, maximising the productivity yield (1.b.) The Transformation and Innovation Committee is developing alternative QIPP schemes to cover any shortfall (2) The Information schedules for both the acute and the CHS contract contain clauses which require the Trust to provide a full patient level Minimum Dataset (MDS) for both activity charged as AHP and activity charged under the CHS contract. Both sets of data will need to be provided in order for AHP activity to be paid. This will enable full validation and avoid the risk of double-charging.

1-Guidance and briefing documents 2-QIPP schemes 3-Information schedules



Initial

4x5

+’ve Current 2x5 Date added 1-Outcome of clinically agreed

productivity metrics 2-In-year additional QIP schemes 3- Information schedules attached to both contracts

Forecast Y2

2x5


Forecast Y5 2x5

Governing Body Lead


Henry Black Domain 4,5,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Henry Black None Comment Lead Committee Governing Body agenda item ref None FPQ Standing item 2.2.2 Finance and Activity report Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus)

45

-None identified at present -None identified at present -None identified at present

46

Allocation Issues and Constraints Comment: For 2014/15 no further work required.

1. In Q1 of 2014/15 the CCG is required to transfer resource allocation via an IAT (Inter-Authority Transfer) to NHSE to cover the resource associated with specialised commissioning

which was incorrectly transferred in 2013/14. This exercise is being handled nationally and is referred to as the consolidation exercise. The impact is expected to be cost neutral as both the allocation and the charge will transfer as part of the same process. The resource covers a relatively small quantum of activity which was incorrectly mapped at the point of PCT budget disaggregation. The errors occurred due to the high degree of complexity and ambiguity involved in the classification of some elements of activity and thus problems with assigning to the correct commissioner. The national exercise has sought to use Trust data in some cases to establish who the correct commissioner should have been. This is a particular problem with Barts Health as the quality of the data does not support absolute accuracy.

2. In addition, all CCGs are required to contribute to a national risk pool to cover retrospective CHC allocations which did not transfer from PCTs to CCGs as anticipated. This will require a transfer of £1.3m non-recurrently to cover the anticipated level of claims expected to be settled nationally. However, this sum only covers a proportion of the total expected settlement value, and there is a risk that a significant additional contribution will be required.

Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 3.7


The CCG faces significant budget pressures in the medium and longer term. The risk inherent in the Q1 reconciliation is that errors in the calculation could result in an incorrect value of resource transferring to NHSE, resulting in an allocation shortfall and further budget pressures for the CCG.

1-The process is being managed by a central team funded jointly by London CCGs 2-The CSU is engaging closely with Barts health to ensure that the amounts identified for transfer are accurate

-Terms of reference and working papers from the London SCG technical group -The net value proposed to transfer is relatively very small (£163k), with the largest single element £147k offset by other transfers in the CCG’s favour

There is no control which can be applied to the CCG’s contribution to the CHC risk pool. This is a national requirement and CCGs are statutorily responsible.

None identified at present

Initial

4x4

+’ve Current 3x4 Date added -None identified at present. Forecast Y2 3x4 April 2014


Governing Body Lead

NHS England Scorecard ref -None identified at present. Target 3x4

Henry Black Domain 4,5,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Henry Black None Lead Committee Governing Body agenda item ref FPQ Standing item 2.2.2 Finance and Activity

report Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) -None identified at present. -None identified at present. -None identified at present.

47

Continuing Care Comment: Development work underway: Integrated Commissioning with Local Authority Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 3.8



Risk of increased pressure on the Continuing Care budget as demand for complex packages increases. As technology and life expectancy increase, demand for continuing care packages is expected to rise in the coming years.

-Robust controls in place to assess eligibility -Regular review to ensure all care packages are up to date and appropriate and any change in individuals’ circumstance is appropriately monitored and reflected in the revised package. - Development of integrated personal commissioning with Local Authority.

-Full documented records for each case, including the minutes of assessment panels -Process of continual review is recorded, monitored and reported to CCG -Broadcare database kept live and updated for all cases



Initial

4x4

+’ve Current 3x4 Date added None identified at present Forecast Y2 3x4 April 2014


Governing Body Lead

NHS England Scorecard ref None identified at present Target 3x4

Henry Black Domain 4,5,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Henry Black None Lead Committee Governing Body agenda item ref FPQ Standing item 2.2.2 Finance and Activity

report Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) None identified at present None identified at present None identified at present

48

Financial challenges of other WELC CCGs Comment: Risk rating has been reviewed and redefined based on consideration of overall controls and assurances in place. Whilst as a whole health economy Inner NEL is in a relatively strong financial position, Waltham Forest CCG have a particular challenge due to their historically low level of funding per head of population in comparison to other London Boroughs. WFCCG are currently below target, but should see financial pressures become less challenging relatively as the national move towards target improves the relative position. Lead Committee Comment: FPQ agreed to take assurance from current risk management approach – Nov 21 2014

Risk 3.9



The financial challenges facing other WELC CCGs creates financial instability for the collaborative as a whole.

(1)There is an agreed risk sharing mechanism in place which has quantified the local risks for each CCG and applied mitigations. This has identified the residual gaps across WELC. (2)The WELC CCGs have agreed to enact the risk share formally in order to transfer resource non-recurrently to support Waltham Forest CCG. (3)NHS England had approved in principle as part of authorisation, and are fully engaged and supportive.

(1) The full formal risk share agreement with structure and contribution of each WELC CCG has been completed (2) Minutes of the Governing Body (3) Risk share agreement approved by NHS England. (4) WFCCG have benefited from additional recurrent allocation in 14/15 in recognition of their ‘distance form target’, and are expected to continue to do so until their target allocation is reached



Initial

4x4

+’ve Current 1x4 Date added None identified at present Forecast Y2 1x4 April 2014


Governing Body Lead

NHS England Scorecard ref None identified at present Target 1x4

Henry Black Domain 4,5,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Henry Black None Lead Committee Governing Body agenda item ref Executive Team Standing item 2.2.2 Finance and Activity

report Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus)

None identified at present None identified at present None identified at present

49

Support local people and stakeholders to have a greater influence on services we commission and develop a responsive and learning commissioning organisation Comment: Strengthen the relationship with Healthwatch in line with the recommendations from the 360° review Lead Committee Comment: TBC

Risk 4.1



Not maximising collaborative working and engagement with:

• Patients, carers and the public • CCG Members • External partners / stakeholders

(e.g. local authority, voluntary sector and Community groups).

1-The CCG Communication Strategy and the CCG PPI Strategy 2-The Patient and Public Engagement Lead is on the CCG Governing Body 3-Senior CCG Management representation on members of several partnership boards e.g., HWBB, WELC collaborative. 4-External representation at the Governing Body, Committees of the Governing Body and Programme Boards. 5-Locality Governance structures feeds into the CCG GB. 6-Informal networking opportunities; e.g. bi-monthly GP engagement events, practice visits, placement schemes. 7-Communication mediums e.g. newsletter, GP internet, CCG website Surveys 8-Members of the Joint Communications and Engagement sub-group of the HWBB 9-Each Governing Body Meeting is preceded by a ‘Patient / Members Story’. 10-‘Plain English’ version of the CCG prospectus and handbook produced. 11-All CCG policies and Governing Body reports require consideration of PPE. 12-Large public facing engagement events 13-360° review

1- Strategies 2-Constitution and Governing Body minutes 3-External minutes 4&5-CCG Governance structure 6-Website screenshots 7-newsletters 8&9-Practice visit write ups and feedback from placement scheme 8-‘Plain English’ version of the prospectus 11-The Prospectus. 12-Website screenshots 10&13-Governing Body reports and policies.



Initial

3x4

+’ve Current 2x4 Date added -Jointly developed HWBB Strategy

-Attendance of CCG managers at external meetings and vice versa. -High levels of Web traffic on the CCG website. -PPE reports to NHSE -Governing Body meetings in public attendance. -Successful engagement events

Forecast Y2

1x4


Forecast Y5 1x3

Governing Body Lead NHS England Scorecard ref -None Target (6 months) 1x3

Catherine Boyle Domain 2 and 3 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Ellie Hobart NHSOF4 Lead Committee Governing Body agenda item ref Executive Team Standing item: 1.5 Patient / Member

story Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus)

50

-None identified at present Strengthen the relationship with Healthwatch in line with the recommendations from the 360° review.


51

Challenging discrimination and promoting equality both as an employer and a commissioner of health care services. Comment: This risk was discussed at the Equality and Diversity Committee where a number of additional controls and gaps in control were added. The risk was also rephrased to ensure that it captured the CCGs ambitions as both as an employer and a commissioner.

Risk 5.1



The risk that the services commissioned by the CCG and the CCGs workforce do not reflect the equality and diversity needs or demographics of the local population.

1-The Equality and Diversity Committee of the Governing Body established with sufficient Governing Body, management and expertise to deliver on all E&D requirements. 2- All business cases to be reviewed by the newly formed Equality and Diversity Committee. 3-TIC to ensure that all business cases have given sufficient consideration to Equality and Diversity issues. 4-CSU SLA reviewed as part of a rolling programme by the Equality and Diversity Committee 5-All papers to the Governing Body require consideration of Equality and Diversity issues. 6- Job descriptions and employment process compliant with equality and diversity legislation

1-Equality and Diversity Committee terms of reference 2&3-Minutes of the E&D and TIC meetings.

-Establish the diversity of the CCG Governing Body and employees. -Complete the review of the Equality and Diversity Strategy - Conduct an assessment of impact of service changes to E&D.

-Minutes of the contract review meetings

Initial

3x4

+’ve Current 3x3 Date added Stonewall Health Champion

review Forecast Y2 1x3


Forecast Y5 1x3

Governing Body Lead

NHS England Scorecard ref None identified at present. Target 1x3

Dr Haroon Rashid Domains 1,2,3,4,6 Trajectory Management Lead CCG Delivery Dashboard See Table 1 Jane Milligan NHSOF2 Lead Committee Governing Body agenda item ref Equality and Diversity Committee

July 2014 – Item 4.8: Equality and Diversity Committee summary.

Actions HIGH priority (30 days) MEDIUM priority (30 to 90 days) LOW priority (90 days plus) None identified at present Complete the review of the Equality and Diversity Strategy. Conduct an equality impact assessment of new business

cases’ E&D considerations. Establish the diversity of the CCG Governing Body and employees.

Escalated from the CCG risk register


52

Executive summary

The Objective Scorecard aims to give an overview of how the CCG is delivering against its priorities. Key updates for November are:

High Quality Health and Social Care Services: Amber (unchanged)

- Achievement of Cancer 2ww continues to be Red. However performance has improved and the most recent validated data (September) shows an improvement from 85.8% to 87.7%

- Dementia diagnosis has improved to 66.45% but remains Amber due to being below the target rate of 67% YTD

- Mental Health Bed occupancy continues to be green despite a small increase to 79.1%

- Metric for improved quality in children’s services remains grey as Barts Health have not reported on this metric in December

- Continuity of Care in Maternity: no reporting by Barts Health in Q2 CQUIN report as specified

Integrated Services: Green (was amber in November)

- Integrated Care Dashboard showing admissions and readmissions for the IC target population reducing month on month since introduction of teams in October 2013. Indicator changed to Green.

- Non elective admissions per 1000 for those with mental health needs. There was been a small reduction against the baseline. Changes from amber in September to green in January

Governing Body Enclosure

Date of meeting 27th January 2015 D

Agenda item 2.2

Title of report: TH CCG Objective Scorecard

Author(s): Josh Potter – Deputy Director of Commissioning and Transformation – NHS Tower Hamlets CCG


John Wardell – Deputy Chief Officer - NHS Tower Hamlets CCG

Josh Potter – Deputy Director of Commissioning and Transformation - NHS Tower Hamlets CCG – 02036882518 – [email protected]

53


Vibrant and Stable Health and Care Economy: Amber (was green in November)

- A&E activity has increased this quarter and is 5.8% above plan YTD (as of 14th January). Changed from green to amber

- First outpatient attendances are performing above plan YTD. It is unclear what impact waiting times initiatives are having in increasing activity. Changes from Green in November to Amber in January

Support local people and stakeholders to have a greater influence on services we commission and develop a responsive and learning commissioning organisation: Green (unchanged):

- There are 37 opportunities for engagement booked in for 2014/15, against a target of 20

Recommendation

Information Approval To note x Decision

This is the key verb of what is required. Make a clear articulation of what the board is being asked to agree/discuss/note or for information

Conflicts of Interest NA

Key issues NA

Report history Updates to the scorecard go to each Governing Body Meeting


This report is a public document and published on the CCG website.


The Scorecard is both a control measure and assurance against several risks affecting the CCGs strategic objectives.


NA

Resource requirements NA

Next steps Outlined in update

54

Overall RAG Rating

RAG Local Priority Metric Target Performance to date CCG Lead

Urgent Care: Streaming, right place right time

People streamed in 14/15 (quality premium measure) 10000 On track VP

Cancer waiting times Achievement of 2ww 93% 87.7% based on September Data SE

Continuity of Care for Maternity% of pregnant women needing antenatal/postnatal care in receipt of “continuity of

care” by year end90%

Barts Health have failed to report on this metric as agreed in the Q2 CQUIN

ML

Dementia diagnosis % of people with dementia recorded on primary care registers 67% 66.45% JL

Improving Access to Psychological Therapies

Number of people entering treatment 15%7.02% for Q1 and Q2 forecast 15.15%

by year endJL

Mental health inpatient occupancy Occupancy of acute adult wards at the Tower Hamlets Centre for Mental Health ≤85% 79.10% JL

Improved quality in community based childrens services

Patients to achieve their goals on discharge/review for CCNT, OT & Physio, SLT, Specialist Children's Clinics, Continence

95%KPI unavailable as not reported by

Barts Health SE

Non-elective admission rate per 1000 population (for very high & high risk patients)Improvement on Baseline

Improvement on baseline VTB

Proportion of patients readmitted as an emergency 30 days after discharge (for very high & high risk patients)

Improvement on Baseline

Improvement on baseline VTB

Non-elective admissions rate per 1000 population of people identified as have dementia, depression or SMI in primary care (for very high & high risk patients)

Improvement on Baseline

Currently shows very small improvement against baseline

VTB/JL

Last Years of Life Choice of Place of DeathMetric in

developmentMetric in development VTB

Access to primary care mental health services

No of people receiving support from the primary care MH service 300 YTD 247 YTD JL

Deliver planned suplus CCG Budget performanceForecasting

BalanceForecasting Balance HB

Planned Care: 1st outpatient appointments

Referral rate At or below planCurrent overperformance on first

outpatient attendancesSA

Urgent Care: A&E Activity Activity vs plan NAA&E activity 5.8% above plan YTD despite successful UCC streaming

VP

Prescribing spend Performance against budgetForecasting

BalanceForecasting Balance SB

PPI opportunities across the CCG annually 2037 opportunities by the end of

2014/15CB

Number of people recruited and supported to become 'patient leaders'.Number of patient leaders offered opportunities to work with CCG.

155-7

15 in placeOn track - Work to begin from Oct

CB

Staff PDPs and Objectives 100% coverage 100% 100% JM

Appraisals 100% of those due appraisals 100% 100% JM

CCG Barometer Quarterly 100% 100% JM

Understanding how our plans impact on our community

Commissioning plans subjected to E&D impact assessment 100% 100% HP

Delivery of Time to Change Pledge Delivery of Action PlanDelivery of Action Plan

Organisational healthcheck underway: 1:1 Interviews completed, Survey due

for completion by all staff by Sept; Mental Health 1st Aid training offered

and uptake good

JM

CCG Objective Scorecard. January 2015

Challenging discrimination and promoting equality

both as an employer and a commissioner of health

care services.

Reduction in emergency admissions for Integrated Care Population

High quality Health and Social Care Services

Integrated services to meet individual mental, physical and social care

needs

Creating a vibrant and sustainable health and

social care economy

Support local people and stakeholders to have a

greater influence on services we commission

and develop a responsive and learning

commissioning organisation

High Impact PPI

55


Date of meeting January 27 2015 E

Agenda item 2.3.1

Title of report: Month 8 Finance report – 2014/15

Author(s): Henry Black – Chief Finance Officer Andrea Antoine – Deputy Chief Finance Officer


Henry Black – Chief Finance Officer – NHS Tower Hamlets CCG

Andrea Antoine – Deputy Chief Finance Officer [email protected] - 020 3688 2510

Executive summary

The month 8 report provides the Governing Body with the financial position of the CCG as at 30 November 2014 and consists of the following:

- Executive Summary,

- Key risks and issues,

- Revenue Financial Position,

- Statement of Financial Position,

- Cash Position and forecast and

- Payment Performance Measures position.

Recommendation


To note the content of the report, and discuss any actions required

Key issues • Acute provider data issues – specifically Barts and the Contract Query notice Issued

• Barts Health reported contractual over-performance The Month 8 report shows the CCG is projecting a surplus of £11.9m.

Conflicts of Interest There are no identified conflicts of interests.

Report history Finance, Quality & Performance (FPQ) meetings (CCG)- Information obtained at this meeting helps inform this Board report


N/A

57



Addresses several corporate objectives, those around finance, ensures the governance body is sighted on key finance and performance targets:

Strategic Objective 3: Creating a thriving and stable health and social care economy

Strategic objective 4: Delivering against our statutory duties.


N/A

Resource requirements None

Next steps Action and next steps for each area identified is covered in the report.

58

Month 8 Finance Report – 2014/15

Executive Summary

This report provides an update on the financial position for the CCG at Month 8 (November 2014) and a forecast for the year. At month 8 the CCG is reporting a year to date surplus of £7.9m and forecast surplus of £11.9m, in line with the CCG’s Financial Plan. However, commissioning reserves are required to offset pressures on contract activity, particularly in the acute sector in order to achieve the targeted position.

Key Risks and Issues The main financial risks facing the CCG can be summarised as follows:

1. Contract finalisation: a. Barts Health – The contract has been agreed and signed off at £128.7m,

however the arbitration ruling has limited our ability to extract as much productivity gains from the contract as originally planned, this has been reduced by £527k.

b. CHS – the contract has been agreed at £40.3m, awaiting sign off. c. ELFT – the contract has been agreed and signed at £35.8m including

investments of £0.9m. d. The following 2014/15 associate contract agreements are still unsigned at

month 6; BHRUT, Homerton and Imperial.

2. 2013/14 closedown – Barts Health. The contracting team are engaging with counterparts from Barts Health to finalise the 13/14 position. As in any year with a PbR contract, the agreed year-end balance reflected in our final accounts was based on M10 freeze data, M11 flex data and an estimate for M12. In addition it included a total value of challenges of around £10m. This means that the final settlement may potentially be marginally higher or lower than the total value reported in our accounts. At the time of writing the contract challenges process indicates that we are due a rebate in the region of £1-2m, however this has not been agreed by Barts and until agreement is reached this is not secure.

59

3. Contract Query Notice (CQN) – Barts Health. On the 18th July 2014, the NEL CCG’s issued Barts Health with a Contract Query Notice in respect of a number of contractual breaches, principally around unacceptable RTT waiting times but also due to over-performance and poor data quality leading to problems with validation. The main issues contained within the CQN which have a material financial impact are as follows: - High levels of un-coded activity Month 1 and 2, which is causing severe

difficulties in assessing an accurate financial position. - An increase in activity added to the month 1 position following the freeze date - The reported position is 9.4% over and above the plan. In accordance with the contract, commissioners met with representatives of Barts Health and agreed a Remedial Action Plan (RAP) to remedy the breaches, with a number of key actions and milestones. The consequences set out in the contract of failure to agree the RAP, or failure to achieve any of the milestones contained within the RAP, are that commissioners shall withhold 1% of contract value per month for up to 6 months, with those funds retained permanently if the remedy is not actioned satisfactorily by the end of that period.

4. Contractual Penalties – Barts Health

The standard NHS contract contains a number of KPIs which carry financial consequences of breach. These cover a range of performance targets, including delivering RTT waiting times for admitted, non-admitted and incomplete pathways as well as heavy fines for patients waiting more than 52 weeks. Performance on RTT was extremely poor across the whole of London during 2013/14 and has continued to deteriorate. Barts Health has suffered from particularly severe problems in delivering the national requirements, and as a result the fines levied through the contract are high, forecast to be in the region of £4m for THCCG and £20m as a whole across all 12 associates to the contract. Barts has a planned financial deficit in the region of £43m but is reporting significant risk that the final outturn position will be substantially worse than this. By imposing the contractual fines, THCCG needs to balance the benefits of applying contractual measures designed to penalise poor clinical care with the obvious impact on the Trust’s finances, and the potential adverse consequential impact on its operational capacity. In light of this, CCG executives are discussing with the Trust how a jointly agreed plan may be able to deliver the quality improvements required.

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5. CHC Liability At Month 6 the CCG transferred £1.3m to NHSE, which is the CCG’s share of the 2014/15 Continuing Health Care risk share pool.

Revenue Resource Allocation The table below shows the movement from Month 7 to Month 8.

Tower Hamlets CCG - 2014/15 Revenue Resource Limit at Month 8

M7 Opening

RRL

In Month movements

Closing M8 RRL

2014/15 Revenue Resource Limit £000's £000's £000's Programme Baseline Allocation (322,139) (322,139) Growth Uplift as per Growth % (6,894) (6,894) Recurrent Other (513) (513) CCG Running Cost Allocation on Constrained Population Size (6,766) (6,766) Non-Recurrent - Previous Year's Surplus \ (Deficit) C'fwd (11,855) (11,855) Recurrent - GP IT (716) (716) Recurrent - GP IT Transitional funding (226) (226) Non-Recurrent - IAT Transfer to WFCCG 2,000 2,000 Non-Recurrent - 14/15 RTT Funding (6,264) (6,264) CEOV Funding (1,666) (1,666) Winter Resilience (1,791) (1,791) Winter Resilience Tranche 2 (6,053) (6,053) Total Resource Limit (362,882) 0 (362,882)

There were no changes to the allocation in month 8. The last allocations received were in Month 7 and these were tranche 1 and 2 of the Operational Resilience funds of £7.8m, to which once plans are agreed, confirmed and the programme underway the funds will eventually transfer to the providers. The Month 8 Closing Revenue Resource Limit of the CCG is £362.9m

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Revenue Financial Position The CCG’s summary revenue financial position is summarised below.

Tower Hamlets CCG - 2014/15 Financial Position at Month 8

Annual Budget £’000

YTD Budget £’000

YTD Actual £’000

YTD (Under)/Ov

erspend £’000

Forecast Actual £’000

Forecast (Under)/Ov

erspend £’000

DelegatedIn Sector Acute Trusts 132,360 88,240 92,111 3,872 141,242 8,882Out of Sector Acute Trusts 22,674 15,119 16,383 1,264 24,595 1,921Other Acute 4,753 3,169 3,268 99 5,097 344Subtotal Acute 159,787 106,527 111,761 5,234 170,934 11,147

Mental Health 43,038 27,393 27,358 (35) 42,986 (53)Community Health 42,455 28,304 28,297 (7) 42,445 (10)Other Non Acute 21,223 14,575 12,107 (2,468) 20,884 (339)Subtotal Non Acute 106,717 70,272 67,762 (2,510) 106,315 (401)

Prescribing 29,503 19,668 19,668 0 29,503 0Other Primary Care Services 10,523 7,015 6,824 (191) 10,236 (287)Subtotal Primary Care 40,025 26,683 26,493 (191) 39,738 (287)

Reserves 32,138 17,270 14,439 (2,831) 21,340 (10,798)

TOTAL CSU 338,667 220,753 220,455 (297) 338,328 (339)

Corporate 12,360 8,240 8,537 297 12,699 339TOTAL CORPORATE 12,360 8,240 8,537 297 12,699 339

GRAND TOTAL 351,027 228,992 228,992 (0) 351,027 0TOTAL RESOURCE LIMIT (362,882) (236,895) (236,895) 0 (362,882) 0(SURPLUS)/DEFICIT (11,855) (7,903) (7,903) (0) (11,855) 0

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Acute Contracts The total Acute budget is £159.8m. At Month 8 the Acute position is currently showing a year to date overspend position of £5.2m with a full year projected overspend of £11.2m against plan.

The main areas of over performance are in Barts Health, Moorfields, Homerton, Guys and St.Thomas’s and UCL as detailed below. Barts Health At month 8, the Barts Health position shows a year to date over performance of £3.6m, with a projected full year over performance position of £8.4m. The main areas of over performance at month 8 are shown in the table below.

Provider Annual Budget (£000's)

YTD Budget (£000's)

YTD Actuals (£000's)

YTD Variance (£000's)

YE Forecast (£000's)

Forecast Variance (£000's)

Chelsea and Westminster Hospital NHS Foundation Trust 421,129 280,746 345,523 64,777 503,760 82,631Barking, Havering and Redbridge Hospital NFT 703,779 469,184 469,184 0 703,779 (0)Barnet and Chase Farm Hospitals NFT 60,376 40,245 21,761 (18,484) 32,572 (27,804)Barts Health NHS Trust 128,722,362 85,814,904 89,421,856 3,606,952 137,207,600 8,485,238BMI HEALTHCARE LTD 1,059,598 706,392 927,332 220,940 1,390,998 331,400Great Ormond Street Hospital for Children NHS Foundation Trust 358,640 239,088 227,008 (12,080) 339,906 (18,734)Guy's and StThomas's NHS Foundation Trust 2,046,223 1,364,144 1,801,005 436,861 2,701,507 655,284Homerton University Hospital NHS Foundation Trust 3,145,295 2,096,856 2,361,446 264,590 3,542,169 396,874Imperial College Healthcare NFT 714,266 476,176 371,186 (104,990) 557,632 (156,634)King's College Hospital NHS Foundation Trust 352,963 235,304 318,747 83,443 477,769 124,806London Ambulance Service NFT 8,650,707 5,767,136 5,767,136 0 8,650,707 0Mid Essex Hospital Services NFT 67,369 44,905 56,956 12,051 85,254 17,885Moorfields Eye Hospital NHS Foundation Trust 3,618,182 2,414,008 2,701,596 287,588 4,052,394 434,212NCAS/OATS 2,483,174 1,655,451 1,831,344 175,893 2,747,016 263,842NHS NEWHAM CCG 191,000 127,328 127,328 0 191,000 0NHS WALTHAM FOREST CCG 301,000 200,664 200,664 0 301,000 0North Middlesex University Hospital NFT 131,844 87,896 104,656 16,760 156,850 25,006North West London Hospitals NFT 108,151 72,096 94,889 22,793 142,167 34,016Other Acute 669,818 446,536 369,493 (77,044) 750,066 80,248ReAdmissions 1,600,000 1,066,661 1,066,664 3 1,600,000 0Royal Brompton and Harefield NHS Foundation Trust 65,657 43,768 51,940 8,172 77,774 12,117Royal Free Hampstead NFT 413,492 275,662 280,957 5,295 501,887 88,395Royal National Orthopaedic Hospital NFT 537,870 358,576 343,230 (15,346) 513,873 (23,997)St George's Healthcare NFT 172,859 115,232 96,061 (19,171) 143,914 (28,945)The Royal Marsden NHS Foundation Trust 95,299 63,520 64,677 1,157 91,887 (3,412)University College London Hospitals NHS Foundation Trust 2,919,136 1,946,759 2,220,946 274,187 3,293,531 374,395Whittington Hospital NFT 176,767 117,838 117,838 0 176,767 0TOTAL ACUTE 159,786,956 106,527,075 111,761,423 5,234,348 170,933,779 11,146,823

Tower Hamlets CCG 2014/15 Acute Financial Position at Month 8

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Inpatient Non Elective – over performance in this area relates predominately to respiratory, which has seen an increase compared to last month, this coincides with the colder weather. Outpatients – over performance in this area specifically relate to first and follow up appointments. In the main the increase in this area is related to physiotherapy which includes community activity, to which a challenge has been raised. Critical Care – It is unclear what the reasons for over performance in this area, therefore this has also been included within the Contract Query Notice, in order for the Trust to advise the reason for the increase. The CSU has recommended that an audit should be carried out to establish the cause, as well as find out whether there is any activity which should otherwise be charged to NHSE. Financial Adjustments – this includes all expected adjustments expected by the end of the year these include; Emergency Readmissions, Productivity metrics and claims. Moorfields At month 8, Moorfields position shows a year to date over performance of £288k, with a projected full year over performance position of £434k. This includes an RTT adjustment to the overall position of £170k. The main driver of this position is in Day cases (£164k ytd), which is predominately in the areas of Phacoemulsification cataract extraction and lens implant, and Enhanced cataract surgery. UCL At month 8, UCL’s position shows a year to date over performance of £274k, with a projected full year over performance position of £374k.

Barts Health - Financial Position @ Month 8

M8 YTD Variance

Forecast Variance

Point of Delivery £000's £000'sA&E 108 227Inpatient Non Electives 2,647 5,559Inpatient Electives 938 1,969Outpatient 3,483 7,315Maternity (1,110) (2,331)Critical Care 1,978 4,153High Cost Drugs 10 20Other 80 168CQUIN (0) (0)Financial adjustments (4,527) (8,596)Total 3,607 8,485

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The majority of the year to date over performance, relates to maternity (£108 YTD) which has shown a 24% increase in births compared to last year. Another area of high over performance is in Critical Care (£79k ytd),due to the cost of 78 bed days against a year to date plan of 24 days. Guy’s and St. Thomas’s At month 8, Guy’s and St Thomas’s position shows a year to date over performance of £436k, with a projected full year over performance position of £655k. This includes an RTT adjustment to the overall position of £175k. The majority of the year to date over performance, relates to maternity (£194 YTD) which has shown a 206% increase in births compared to last year. The over performance in Elective care (£163k YTD), relates mainly to T&O and Urology. Homerton At month 8, the Homerton position shows a year to date over performance of £265k, with a projected full year over performance position of £396k. This includes an RTT adjustment to the overall position of £62k. The over performances mainly relate to;

- Critical Care ytd £118k – This overspend is due to the cost of 89 bed days against a year to date plan of 40 days.

- Outpatient attendances mainly attributable to Cardiology ytd 76k. - Elective Procedure ytd £58k – mainly in the areas of T&O, General Surgery and

Gastroenterology. Healthcare Provision A summary analysis of the year to date and the forecast for healthcare provision budgets are shown below.

The total Healthcare Provision budget is £146.7m. At Month 8 the Healthcare Financial Position is currently showing a year to date underspend position of £2.7m with a full year projected underspend of £688k against plan.

Area

Annual Budget (£000s)


YTD Actual (£000's)




Community Health 42,455 28,304 28,297 (7) 42,445 (10)Continuing Care 14,394 10,022 9,951 (72) 14,287 (107)Mental Health 43,038 27,393 27,358 (35) 42,986 (53)Other 6,829 4,553 2,157 (2,396) 6,597 (232)Primary Care 40,025 26,683 26,493 (191) 39,738 (287)Healthcare Provision Financial Position 146,742 96,955 94,255 (2,700) 146,054 (688)

Tower Hamlets CCG 2014/15 - Healthcare Provision Financial Position at Month 8

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The main areas of ytd underspend are within Integrated Care, ICES and NHS111 – however, we are expecting these costs to materialise before the end of the year. Corporate Costs For this financial year the CCG’s running costs allowance is £6.766m. As at month 8 the CCG is within plan to spend within its Running cost Allocation. However, the overall corporate financial positon is overspent by £339k. This relates mainly to additional CSU costs outside of the core costs which had not been budgeted.

This will be continued to be monitored on a monthly basis, together with ongoing budget holder meetings, with all movements (increases and/or decreases) to the corporate budgets as a whole, being approved by the CCG’s SMT. QIPP The Tower Hamlets QIPP plan for 2014/15 has a total gross value of £11.8m, with a net Qipp savings of £6.2m.

Department

Annual Budget (£000s)


YTD Actual (£000's)




ADMINISTRATION & BUSINESS SUPPORT 183 122 92 (30) 161 (21)BUSINESS DEVELOPMENT 551 367 335 (32) 526 (25)CEO/ BOARD OFFICE 379 253 219 (34) 344 (36)CHAIR AND NON EXECS 407 271 275 4 416 9COMMISSIONING 51 34 60 26 106 55COMMUNICATIONS & PR 255 170 136 (34) 231 (24)CONTRACT MANAGEMENT 201 134 134 0 201 0CORPORATE COSTS & SERVICES 3,007 2,005 2,279 275 3,005 (3)EDUCATION AND TRAINING 0 0 0 0 0 0ESTATES AND FACILITIES 0 (0) (0) 0 0 0FINANCE 1,459 972 802 (171) 1,509 50STRATEGY & DEVELOPMENT 273 182 178 (4) 267 (6)Sub-total Running Costs Allowance 6,766 4,510 4,510 (0) 6,766 0

Programme Projects 5,594 3,729 4,027 298 5,933 339Sub-total Other Corporate Costs 5,594 3,729 4,027 298 5,933 339

Total Corporate Financial Position 12,360 8,240 8,537 297 12,699 339

Tower Hamlets CCG -2014/15 Corporate Financial Position at Month 8

66

At month 8 the Qipp summary shows a ytd under achievement of £291k with a projected full year overachievement of £2k. Recommendations The Governing Body is asked to note the contents of this report, the risks highlighted and the management action undertaken to mitigate these risks.

Appendices

1. Statement of Financial Position 2. Cash Position and Forecast 3. BPPP

Programme Programme Delivery Outcomes

Net QIPP Plan

(Savings)/ Investment

£000's

YTD QIPP Plan


£000's

YTD QIPP Achievement


£000's

YTD QIPP (under)/ over achievement

£000's

Net QIPP Forecast


£000's

Forecast (under)/

Over achievement

£000's

Budget Adjustments (106) (71) (71) 0 (106) 0

Children and Young People 383 255 270 (15) 405 (22)

Community Health Service (234) (156) (1,070) 914 (1,605) 1,371Integrated Care (3,256) (2,171) (2,427) 256 (3,655) 399

Long Term Condition (100) (67) 40 (107) 56 (156)Mental Health 17 11 140 (129) 210 (193)Planned Care (2,240) (1,493) (433) (1,060) (741) (1,479)

PPE 50 33 27 6 50 0Prescribing (1,101) (734) (489) (245) (1,082) (19)

Primary Care Quality 452 301 201 101 331 122Urgent Care (74) (49) (36) (13) (74) 0

Total (6,209) (4,139) (3,848) (291) (6,211) 2

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Statement of Financial Position

Tower Hamlets CCG £000Statement of Financial Position as at 30th November 2014

Nov 2014

NON-CURRENT ASSETS

Property, Plant and Equipment - Intangible - Other Financial Assets - Trade and Other receivables - TOTAL Non Current Assets -

CURRENT ASSETSInventories - Trade and Other Receivables 550 Other Financial Assets - Cash and Cash Equivalents 903

TOTAL Current Assets 1,453

TOTAL ASSETS 1,453

CURRENT LIABILITIESTrade and Other Payables (56,283) Provisions (216) Borrowings - TOTAL Current Liabilites (56,499)

NET CURRENT ASSETS/(LIABILITIES) (55,046)

Trade and Other Payables - Provisions - Borrowings - TOTAL Non-Current Liabilites -

TOTAL ASSETS EMPLOYED (55,046)

FINANCED BY:

TAXPAYERS EQUITY

General Fund (55,046) Revaluation reserves - TOTAL TAXPAYERS EQUITY (55,046)

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Cash Position and Forecast

Tower Hamlets CCG April May June July August September October November December January February March Cash position and forecast 2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015 2015 Position as at 30th November 2014 Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast

RECEIPTS

Balance bfwd 160,689 1,784,716 179,888 234,702 2,706,664 4,668,879 6,270,330 4,949,613 1,240,150 135,000 228,186 288,068

NCB Drawdown 26,500,000 24,000,000 26,000,000 26,000,000 25,000,000 23,000,000 23,000,000 20,000,000 25,386,000 25,000,000 30,000,000 38,307,311

Other 2,112,853 89,600 17,760 11,143 574,839 285,356 178,524 2,565,109 75,000 25,000 25,000 25,000

PCS Payments ReimbursementsVAT 243,671 105,158 78,459 110,072 105,923 - 62,224 86,693 80,000 80,000 80,000 120,000

TOTAL 29,017,213 25,979,474 26,276,107 26,355,917 28,387,426 27,954,235 29,511,078 27,601,415 26,781,150 25,240,000 30,333,186 38,740,379

PAYMENTS

Creditors NHS 20,630,789 21,472,011 23,534,285 20,008,477 20,401,527 18,935,343 20,369,002 24,032,342 23,229,118 20,470,000 25,766,947 32,402,915

Creditors BACS 6,405,105 4,101,269 2,301,139 3,399,008 3,082,458 2,507,650 3,909,788 1,987,989 3,100,000 4,250,000 3,957,053 5,903,805

Creditors CHAPS 649 358 357 - - - 36,330 25,000 25,000 25,000 25,000

Salary CHAPS 7,443 - 535 1,120 23,430 1,755 - - 5,591 -

Cleared Payable Orders 10,811 2,464 4,771 4,309 2,782 5,500 5,522 11,880 22,566 8,656 30,027 -

Salaries & Wages 96,889 106,247 113,910 135,000 119,050 127,454 143,632 139,957 140,000 140,000 140,000 140,000

Pensions 36,029 39,362 37,022 36,937 38,110 38,138 38,972 42,820 43,000 43,000 43,000 43,000

Tax & NI 51,256 70,085 49,852 63,159 74,025 68,633 69,501 97,066 75,000 75,000 75,000 75,000

Standing Orders/Direct Debits 1,559 - 1,559 - - 1,559 2,000 - - 2,000 -

Foreign Payments - - 387 - - - 9,062 11,406 - - -

Other 60 56 69 59 60 67 59 64 60 158 500 659

- - - - - - - - - - - -

TOTAL 27,232,497 25,799,586 26,041,406 23,649,253 23,718,547 21,683,905 24,561,465 26,361,265 26,646,150 25,011,814 30,045,118 38,590,379

BALANCE CFWD 1,784,716 179,888 234,702 2,706,664 4,668,879 6,270,330 4,949,613 1,240,150 135,000 228,186 288,068 150,000

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BPPP

Tower Hamlets CCGPayment Performance Measure Number Value Number ValuePosition as at 30th November 2014 £'000 £'000

Non-NHS Creditors

Total Bills paid in the year 420 2,048 3,822 27,954

Total Bills paid within target 389 1,955 3,527 23,549

Percentage of Bills paid within target 92.6% 95.5% 92.3% 84.2%

NHS Creditors




All Creditors




Comparison with prior Year Performance (2012/13) Number Value Number Value

Percentage of Bills paid within target - Non NHS 90.5% 88.0% 84.9% 83.6%

Percentage of Bills paid within target - NHS 95.6% 99.8% 84.5% 86.9%

CumulativeNov-14

70


Date of meeting 27th January 2015 F

Agenda item 2.3.2

Title of report: Tower Hamlets Finance & Activity Summary Report

Author(s): Huw Wilson-Jones – Deputy Director of Contracts (Barts Health), CSU Deane Kennett – Assistant Director of Contracting, CSU

Presented by: For further information

Huw Wilson-Jones: Deputy Director of Contracts (Barts Health), CSU

Deane Kennett – Assistant Director of Contracting, CSU – [email protected]

Executive summary

The report provides a high level overview of finance and activity across Tower Hamlets for the month of November 2014 (based on October 2014 activity data). The report highlights the key issues, current performance, key actions and a delivery RAG rating for major providers providing healthcare services in Tower Hamlets.

Recommendation


This is the key verb of what is required. Make a clear articulation of what the board is being asked to agree/discuss/note or for information

Conflicts of Interest N/A

Key issues • YTD Position: £7,903k underspent. Forecast outturn position: £11,855k underspent.

• Main drivers for YTD position:

• Barts £3,607k overspend.

• Guys £437k overspend.



• Reserves have been adjusted to reflect a YTD underspend of £7.9m.

Report history Information presented at the CCG Finance & Activity meetings informs this Board report


N/A

71



• This paper affects Strategic Objectives 3: Creating a thriving and stable health and social care economy

• The PbR (payment by result) basis of the Barts Health contract represents the main risk in conjunction with the disaggregation of NHS England (including Specialist Commissioned Group) commissioned activity.


N/A

Resource requirements

N/A

Next steps Action and next steps for each area identified is covered in the report. Main areas of work include: Barts Acute

• Q2 reconciliation process is underway with agreed position in some areas.

• CSU have proposed withholding 2% of monthly income according to the contract for month 8 for non-agreement of Remedial Action Plans (in response to Contract Query Notice).

Non-acute Community

• CSU to continue to push data and reporting improvements via CHS Technical Sub-Group including delivery of MDS

72

Finance & Activity Summary Report Tower Hamlets CCG

January 2015

73

Fina

nce

& A

ctiv

ity

CCG Finance Performance, M8 2014/15 Action Am

ber

Year End position: £11,855k surplus

Key Messages • YTD Position: £7,903k surplus. Forecast outturn

position: £11,855k surplus.

• Main drivers for YTD position:

• Barts £3,607k overspend .

• Guys £437k overspend .



• Reserves have been adjusted to reflect a YTD underspend of £7.9m.

Tower Hamlets Finance & Activity Headlines: January 2015

Month 8 Financial Position based on Month 7 Activity data YTD Budget

£’000YTD Actual

£’000YTD

(Under)/Overspend £’000

RAG

Improvement/Deterioration

vs Month 7

Acute 106,527 111,761 5,234 841

Mental Health 27,393 27,358 (35) 92

Community Health 28,304 28,297 (7) (2)

Other Non Acute 14,575 12,107 (2,468) (435)

Prescribing 19,668 19,668 0 0

Other Primary Care Services

7,015 6,824 (191) (148)

Reserves 17,270 14,439 (2,831) 40

TOTAL CSU 220,753 220,455 (297) 388TOTAL CORPORATE 8,240 8,537 297 0GRAND TOTAL 228,992 228,992 (0) 388TOTAL RESOURCE LIM (236,895) (236,895) 0 0(SURPLUS)/DEFICIT (7,903) (7,903) (0) 388

Rag Key: AdverseNo ChangeFavourable

74

Fina

nce

& A

ctiv

ity

Tower Hamlets Finance & Activity Headlines: January 2015 Executive Summary

Ambe

r

Barts Health (Acute) • The key areas of pressure continue to be emergency admitted care, planned procedures and critical care spend. • Over performance in planned care as a whole has decreased due to a correction by the Trust in erroneous excess bed day recording

on publication of M6 Freeze. It is expected there will continue to be over performance here as the Trust manage the RTT targets. • Q2 reconciliation process is underway with agreed position in some areas. • The CSU and CCGs have not signed off all Remedial Action Plans (in response to the Contract Query Notice) and propose

withholding 2% of monthly income according to the contract for month 8. • Escalation to national forum via Star Chamber Forum regarding performance issues at Barts Health in January, feedback in next

month’s report. Mental Health • The ELFT Mental Health Provider continues to meet most contractual requirements. • Adult DNA rates continue to be above threshold however, an action plan is in place and performance is improving month on

month. • The Emergency liaison 4 hour target was not achieved; under performance has been attributed to the lack of a post-discharge suite

at the Royal London, the CCG has escalated this issue to senior members of the Barts team for resolution. and there has been progress with Barts Health on the availability of space in the hospital.

Community Health Services • Contract documentation has been signed by the Provider and is with Newham for signature. • Work continues via the Technical Sub-group on progressing improvements in the quality of activity data that is supplied by the

Trust, with a Data Processing Agreement being put in place to allow the flow of patient level data to the CSU. • Reporting continues to improve month on month and the management of CHS remain very engaged in SPR and technical sub-group

working. • Whilst DNA rates continue to improve they remain high. CCG, CSU and the provider continue to work together to understand

underlying causes and solutions.

Continuing Healthcare • Forecast year end fell again this month from an under spend in M7 of £61k to £107k underspent in M8. M8 saw a number of high

cost Fast Track care packages close along with a moderate increase in applications. 75


Date of meeting 27 January 2015 G

Agenda item 2.4

Title of report: Performance and Quality Report

Author(s): Archna Mathur - Director Quality & Performance (CCG) CSU Performance and Quality team

Presented by: For further information

Archna Mathur – Director Quality & Performance – THCCG Archna Mathur – Director Quality & Performance THCCG [email protected] (020 3688 2528)

Executive summary

This paper provides a high level overview of quality and performance across Tower Hamlets reported for the months of October 2014 to November 2014 where data is available.The report highlights the key issues, current performance against key performance indicators and key actions taken by providers and Tower Hamlets CCG in managing the performance for the main providers of acute, community and mental healthcare in Tower Hamlets.

Recommendation


The Governing Body is asked to note the contents of the report, particularly in relation to the Board Assurance Framework.

Key issues • Cancer Waiting Times: October data for the 2WW (2 week wait) suspected cancer standard and provisional November data is demonstrating achievement against the 93% standard at Trust level with 94.3% and 95.6% respectively in line with trajectory. Performance at the RLH (Royal London Hospital) site remains challenged. The Trust continues to perform against the breast symptomatic standard achieving 97.9% in October.

• 31 day target from decision to 1st treatment improved for October compared to the September position with 95.1% vs. 92.1% respectively.

• 62 day GP referral performance remains challenging with October data showing underperformance against the 85% target with 70.2% at Trust level.

• Trajectories for monthly performance are now in place for the 62 day standard with the aim of achievement by March 2015. The Trajectories for October and November have been exceeded however there is a concern that with a high volume of open pathways c2500, the backlog clearance will create a dip in performance before recovery in line with the trajectory will be

77


seen. • Referral to Treatment (RTT): Barts Health continues to

underperform against the national waiting time standards at speciality and Trust aggregate level and a Board decision has been made to suspend reporting of RTT data. Processes are currently underway to agree the recovery trajectory in line with the Contract Query Notice previously issued. The Barts Health Director of Delivery and Improvement has commissioned an investigative review. Reduction of the 52 week waiters is being prioritised to ensure clearance by the end of March. Trauma and Orthopaedics still remains a challenge for clearance of patients waiting over 52 weeks.

• A&E: Barts Health has failed to achieve the Q3 all types 95% standard delivering 89.79%. Performance is also below trajectory for Q4 to date particularly at RLH and Whipps Cross sites. The RLH has a LOS (Length of Stay) of 5.9 days, above the planned 5.4 days for December, a variance of 9.3%. Bed Occupancy is 5.4% above the target 93% at 98%. Attendances at the RLH are up 4% against plan for December, with adult admissions also above plan. Breaches at RLH are due to bed availability and ED process/capacity. Delayed discharges are affecting bed availability at the RLH due to delays in accessing specialist (tertiary) rehabilitation beds, repatriation of patients, continuing care cases, including a need to identify suitable nursing home placements and disputes. Enhanced CCG support into the RLH site since the start of January has improved discharges of medically fit patients and improved processes for accurate recording.

• The Trust will be implementing the ‘Stepping into the Future’ improvement initiative using the IST (Intensive Support Team) ’Perfect Week’ methodology initially at Royal London Hospital (26 Jan) and Whipps Cross Hospital (9 Feb). The aim of the initiative is to rapidly improve patient flow to improve performance, safety and patient experience. It will initially run over one week (8 days) during which the whole organisation focuses on the RLH site to support improvements in the emergency care pathway. It is hoped that this initiative will lead to a step change in performance at the RLH and Whipps Cross sites with a more sustained performance improvement going forward.

• The aim of the initiative is to rapidly improve patient flow to improve performance, safety and patient experience. It will initially run over one week (8 days) during which the whole organisation focuses on a Hospital to support improvements in the emergency care pathway. Due to the size of Barts Health, the Stepping into the Future programme will be run over three separate weeks across the three main hospital sites - initially at Royal London Hospital (26 Jan) and Whipps Cross Hospital (9 Feb).

• IAPT: Q2 2014/15 access rate was 3.57%. The Cumulative Access rate was 7.02% against the Q2 plan of 7.05%.

• Recovery rate: 43.97% against the plan of 50%. In Q2 1603 people were referred in to the service. 1115 people entered treatment in Q2

• SI (Serious Incidents): Barts Health has ZERO overdue SIs for

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November. The Trust process to manage serious incidents was part of the CQN (Contract Query Notice) issued to Barts Health with a focus now on sustainability.

• SIs for ELFT: there were 13 overdue SIs for November (8 mental health and 5 community) a significant improvement. An action plan to reduce overdue SIs is in place.

• Never Events (Barts Health): There was one NE reported in November, relating to a wrong tooth extraction.

• Never Events for ELFT: Zero never events were reported for November.

• Mixed Sex Accommodation: There were 22 breaches in November, mainly at the Royal London Site. Reasons for this remains critical care step down due to bed capacity and high trauma activity. Comparisons with other London trauma centres shows the RLH to be reporting the highest number of breaches but more analysis is needed to determine if other Trusts are applying the reporting guidance in the same way.

• HCAI (HealthCare Associated Infection) – the year to date total for Cdiff infections is 45 and MRSA is 8 cases (latest data shows 11). New guidance on reporting of Cdiff cases not sure to lapses in care was discussed at FPQ.

• Quality Assurance visits: Latest Quality Assurance visits have been undertaken on wards 14F, 11C and 12C to follow up on a Serious Incident relating to a unexpected death of a patient who whilst in hospital developed a grade 4 pressure ulcer and MRSA. A number of shortfalls were identified on this visit and the issues have been raised with the CAG Directors of Nursing. We are currently awaiting response.

• CQRM: December CQRM was Maternity and sought assurance from the Trust on management of risks in maternity, learning from complaints, themes, analysis and learning from SIs, patient experience through FFT and internal “Great Expectations” programme, maternity workforce, management of capacity at the RLH site, C-section rates and progress with reporting against the maternity dashboard.

• CQC: CQC have undertaken an inspection of the Whipps Cross and the Trust has met with CCGs, NHSE, TDA and CQC themselves to learn of the initial findings and response. The Royal London and Newham sites will be inspected from the 21st January for 2 weeks.

Conflicts of Interest There are no identified conflicts of interest.

Report history Information presented at the CCG Performance & Quality meetings informs this Governing Body report.


The Friends and Family Test (FFT) provides patient feedback to improve service provision as well as NHS Choices providing patient comments on services.


This paper affects all of the risks under Strategic Objective 2: Systems and processes to monitor, challenge and support provider delivery of the NHS Constitution targets.

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Monitoring and actively improving the performance and quality of service provision will have a benifical impact for all patients in Tower Hamlets.

Resource requirements N/A


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Tower Hamlets CCG Month 8 2014/15

Monthly Acute Quality & Performance Report – Summary

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Tower Hamlets CCG – Quality Premium: NHS Constitution rights and pledges

Data source: Unify2

Tower Hamlets CCG

2

The Barts Health Trust board has taken the decision to suspend the monthly mandatory reporting of referral to treatment (RTT) waiting times data from October (including the retraction of September).

* For the purposes of the quality premium, the percentage of Incomplete pathways within 18 weeks will be calculated by summing the numerators (patients waiting within 18 weeks) from each month end and then dividing by the sum of all the denominators (patients waiting) from each month end. This figure does not include data from trusts that are not currently reporting on UNIFY e.g. Barts Health and BHRUT. **The A&E CCG Quality Premium is based on data mapping from NHSE, derived from HES figures. This calculates what proportion of each provider’s activity can be attributed to a given CCG. Any activity under 1% is ignored. The total number of attendances is divided by the total number of 4 hour breaches over a 52 week period is used to calculate an overall percentage for the year.

NHS TOWER HAMLETS CCG

2014-15

Referral to treatment times (18 weeks Incomplete) (April 2014 to November 2014)* 90.31% N 92%

A&E waits - All types (April 2014 to November 2014)** 94.16% N 95%

Cancer waits - 14 days (April 2014 to October 2014) 84.84% N 93%

Category A Red 1 ambulance calls (April 2014 to October 2014) 69.34% N 75%

QUALITY PREMIUM 2014-15(NHS Constitution rights and pledges)

Measure Measure achieved Target

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Key achievements Cancer Waiting Times • For the first time in 7 months, Barts have

achieved the 2ww standard with 94.3% against a target of 93%. It is also the highest achievement for the trust in a year for this standard.

Diagnostic Waits • Tower Hamlets CCG achieved the 6 week

wait diagnostic target for November: 0.36% vs threshold of 1%.

VTE • The Royal London site achieved 95.1%

against this target in September.

Performance issues 18 Weeks Referral to Treatment Times • The Barts Health Trust board has suspended the (RTT) waiting times data from October (including retraction of September).

Without including Barts Health data, Tower Hamlets CCG reported performance for November was: Adjusted Admitted pathway (89.86% against the target of 90%), Non-Admitted pathway (94.97% vs target of 95%) or the Incomplete pathways at (93.90% vs the target of 92%).

Cancelled Operations • Barts Health underperformed in Quarter 2 2014-15 with 89.2% (18 breaches out of 167 cancelled operations, target is 0 breaches). A&E Waiting Times – All Types • Barts Health A&E performance in November was: 90.24% vs. threshold of 95%. (YTD = 93.75%) • Whipps Cross performance was 90.13% in November against the 95% standard. (YTD = 92.81%) Cancer Waiting Times • In October Tower Hamlets underperformed in the 2 week waits urgent referral (89.9% vs. 93%), 31 day 1st treatment standard

(91.9% vs. 96% standard) and the 62 day GP Urgent Referral (66.7% vs. 85% standard). • Barts Health underperformed for the 31 day to 1st treatment (95.1% vs. standard: 96%), 31 day to 2nd subsequent Treatment

for surgery (93.5% vs. standard: 94%), 62 day GP referral (70.2%, standard 85%), and 62 day screening (84.6%, standard 90%).

MRSA • There was 1 reported MRSA bacteraemia case in October assigned to Barts Health. (YTD total = 7). (1 in April; 2 in May; 2 in

June; 0 in July; 0 in August; 2 in September). 1 cases of MRSA were attributed to Tower Hamlets in October. (YTD total = 6). MSA • There were 22 published breaches at Barts Health in November 2014. Of these, 19 were at The Royal London, 1 at Newham

Hospital, 1 at Whipps Cross and 1 at The London Chest Hospital. • Tower Hamlets CCG had 8 breaches in November 2014. All of these occurred at The Royal London. VTE • Barts Health achieved 94.8% VTE risk assessments for September against a target of 95%. C. Difficile • There were 6 cases in October assigned to Barts Health. This takes the YTD total to 45. This was against a YTD threshold of

41 (annual threshold = 71). • There were 2 cases in October attributed to Tower Hamlets CCG. Therefore the YTD total is now at 22. This was against a YTD

threshold of 21 (annual threshold = 38). Ambulance Handover • The Royal London Hospital failed the 15 minute handover (KPI 1) with 54.3% and underperformed against 30 minute handover

(KPI 2) with 99.7% and data completeness rate (KPI 4) with 73.1% in November. Category A, Ambulance Response Times • Category A Red 1 was not achieved in October (64.1% vs. 75% target). • The Red 2 (Cat A 8 min) response was not met in October (57.5% vs. 75% target). • Category A calls: 19 minutes the target was not met October (91.4% vs. 95% target). back to

Main Menu

Tower Hamlets CCG – Summary of Monthly Performance

3

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Trust wide Performance - Cancer Waiting Times Note: The NHS Constitution Quality Premium indicators are highlighted in lilac Top ranked Providers by greatest activity proportion

Barts Health 87.3% 92.0% 93.5% 88.3% 93.3% 88.5% 83.6% 83.9% 85.1% 90.0% 91.7% 91.6% 94.3% 88.7%Homerton 95.2% 98.2% 97.4% 96.2% 96.9% 96.4% 95.4% 96.5% 95.8% 93.8% 95.6% 97.8% 96.4% 95.9%BHRUT 95.1% 94.3% 85.2% 71.3% 88.3% 81.7% 76.1% 76.6% 85.5% 93.8% 93.9% 96.2% 95.0% 88.5%



Barts Health 90.0% 94.4% 100.0% 100.0% 97.2% 97.8% 91.3% 96.7% 86.2% 100.0% 100.0% 96.8% 93.5% 94.4%Homerton 100.0% 100.0% 100.0% 100.0% 85.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%BHRUT 95.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.2% 96.2% 90.9% 100.0% 100.0% 100.0% 97.3%

Barts Health 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Homerton 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%BHRUT 94.1% 100.0% 100.0% 100.0% 96.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.7% 100.0% 99.4%

Barts Health 99.0% 99.0% 97.8% 95.3% 94.5% 95.5% 100.0% 96.5% 96.1% 100.0% 100.0% 95.9% 95.2% 97.4%HomertonBHRUT 97.6% 88.6% 96.2% 95.8% 96.3% 97.6% 100.0% 95.7% 96.6% 98.7% 100.0% 100.0% 98.1% 98.5%


Barts Health 100.0% 94.3% 100.0% 100.0% 87.5% 86.7% 89.5% 100.0% 89.7% 96.0% 83.3% 78.9% 84.6% 89.8%Homerton 0.0% 100.0% 100.0%BHRUT 94.7% 82.8% 100.0% 100.0% 90.9% 93.3% 93.8% 100.0% 82.9% 92.3% 100.0% 82.9% 86.4% 90.6%


Theme KPI / Measure Provider Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14Oct-13 Nov-13 Dec-13 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14

Can

cer W

aits

2 Week Cancer Wait 93%

2 Week Cancer Wait:Breast Symptoms 93%

31 day Cancer Wait:1st definitive treatment 96%

2014-15YTD

2014-15 Target

31 Day Cancer Wait: Subsequent treatment

(Surgery)94%

Theme KPI / Measure Provider Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14Oct-13 Nov-13 Dec-13 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14

Can

cer W

aits


(Chemotherapy)98%


(Radiotherapy)94%

62 Day Cancer Wait: GP Referral 85%

2014-15YTD

2014-15 Target

62 Day Cancer Wait: Screening service 90%

62 Day Cancer Wait: Consultant Upgrade

No thresholds

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Trust wide Performance - A&E 4 hour waiting times Note: The NHS Constitution Quality Premium indicators are highlighted in lilac Top ranked Providers by greatest activity proportion

Royal London Hospital 94.1% 95.6% 91.2% 90.3% 91.3% 93.8% 92.2% 89.8% 90.2% 93.4% 92.7% 92.2% 89.7% 83.4% 90.4%Newham 97.8% 96.9% 97.2% 96.2% 97.0% 97.8% 95.2% 96.8% 97.7% 97.0% 94.1% 95.2% 94.5% 93.1% 95.5%Whipps Cross 94.1% 89.3% 94.0% 91.2% 92.4% 95.9% 92.1% 86.7% 88.3% 91.3% 88.5% 90.7% 88.0% 84.9% 88.7%Homerton 95.5% 96.5% 96.4% 96.5% 96.3% 96.5% 94.9% 95.4% 96.0% 94.8% 96.1% 95.6% 96.0% 95.0% 95.4%Queens Hospital 79.2% 89.2% 84.1% 79.7% 81.5% 83.9% 84.5% 77.7% 76.5% 83.9% 78.1% 79.4% 73.6% 80.4% 79.2%King George Hospital 89.1% 96.1% 87.0% 88.7% 87.7% 89.8% 89.5% 89.5% 91.1% 91.4% 88.6% 89.4% 85.1% 77.5% 87.7%Barts Health 94.5% 94.1% 93.8% 92.2% 93.1% 95.8% 92.9% 90.5% 91.4% 93.6% 91.7% 92.4% 90.3% 86.2% 91.1%BHRUT 82.8% 91.3% 85.4% 82.1% 84.2% 86.1% 86.0% 81.5% 81.3% 86.3% 81.5% 82.7% 77.4% 79.4% 82.0%

Royal London Hospital 95.0% 96.3% 92.3% 91.7% 92.4% 94.6% 93.3% 91.2% 91.7% 94.5% 93.8% 93.4% 91.3% 85.9% 91.8%Newham 98.3% 97.6% 97.8% 97.4% 98.0% 98.5% 96.8% 98.0% 98.5% 98.1% 96.2% 96.9% 96.3% 95.4% 97.1%Whipps Cross 96.4% 93.2% 96.3% 94.7% 95.1% 97.5% 95.2% 91.6% 92.6% 94.4% 92.6% 93.8% 92.3% 90.1% 92.8%Homerton 95.5% 96.5% 96.4% 96.5% 96.3% 96.5% 94.9% 95.4% 96.0% 94.8% 96.1% 95.6% 96.0% 95.0% 95.4%Queens Hospital 79.4% 89.5% 84.7% 80.5% 82.2% 84.5% 85.1% 78.6% 77.4% 84.5% 79.1% 80.2% 74.6% 81.1% 80.0%King George Hospital 93.0% 97.4% 91.6% 92.6% 92.0% 93.5% 93.5% 93.1% 93.9% 94.4% 92.5% 92.9% 89.8% 85.2% 91.9%Barts Health 96.0% 95.7% 95.6% 94.5% 95.0% 97.1% 95.0% 93.4% 94.0% 95.5% 94.1% 94.6% 93.1% 90.2% 93.7%BHRUT 85.4% 92.7% 87.9% 85.0% 86.8% 88.4% 88.5% 84.5% 84.2% 88.5% 84.5% 85.4% 80.9% 82.7% 84.8%

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0BHRUT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0BHRUT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Category A calls resulting in emergency response arriving

within 8 mins (RED 1)

London Ambulance Service NHS Trust 75.1% 74.3% 74.9% 79.0% 81.9% 81.6% 76.8% 72.9% 70.1% 70.3% 68.7% 61.9% 64.1% 69.3% 75%


within 8 mins (RED 2)



within 19 mins


Theme KPI / Measure Provider Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14Oct-13 Nov-13 Dec-13

0

Jul-14 Aug-14 Sep-14 Oct-14 Nov-14

0

Acc

iden

t & E

mer

genc

y an

dA

mbu

lanc

e C

alls

and

Han

dove

r

A&E Type I Performance 95%

A&E All Types Performance 95%

2014-15YTD

2014-15 Target

No of waits from decision to admit to admission (Trolley waits

- over 12 hours)

Urgent cancelled operations 2nd time

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Trust wide Performance Validated provider performance data is only available until September 2014 due to CSU/CCGs

access restrictions to unpublished data.

Homerton 0 0 0 2 0 1 1 1 0 0 0 0 0 2Barts Health 0 2 0 2 2 1 1 2 2 0 0 2 1 8Moorfields Eye Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0 0UCLH 0 1 0 1 0 0 0 0 0 1 0 0 0 1Royal Free Hospital 2 0 2 0 1 0 0 0 0 1 0 0 2 3Barnet & Chase Farm 2 0 2 0 1 0 0 0 0 1 1Guy's and St. Thomas' 0 0 0 0 1 1 0 0 0 0 1 0 1 2St. George's Healthcare 0 1 0 2 1 0 0 1 1 1 0 0 0 3

Homerton 0 0 1 1 0 0 1 1 0 0 1 1 1 5 2Barts Health 4 8 7 11 10 5 6 8 5 5 9 6 6 45 71Moorfields Eye Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0UCLH 8 6 9 5 10 9 4 10 7 12 11 13 4 61 57Royal Free Hospital 5 4 3 5 8 9 7 6 4 4 5 9 5 40 58Barnet & Chase Farm 3 2 2 4 7 6 5 5 2 1 13 4Guy's and St. Thomas' 6 4 3 3 3 6 5 5 8 6 4 5 2 35 n/aSt. George's Healthcare 0 2 2 1 1 2 3 3 5 3 5 3 3 25 n/a

Homerton 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barts Health 16 14 35 48 25 29 40 25 28 35 46 30 22 22 248Moorfields Eye HospitalUCLH 3 0 0 0 0 0 0 0 0 0 0 0 4 0 0Royal Free Hospital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barnet & Chase Farm 4 3 0 2 16 11 1 19 9 0 0 0 0 0 29Guy's and St. Thomas' 0 0 0 0 1 0 0 0 0 0 0 0 4 4 8St. George's Healthcare 2 4 2 10 4 0 5 0 2 0 0 0 0 0 7

Homerton 94.9% 94.4% 92.7% 93.6% 95.0% 96.7% 96.8% 96.8% 98.0% 97.3% 96.6% 96.7% 97.0%Barts Health 95.7% 96.4% 95.9% 95.7% 96.2% 95.3% 95.5% 95.0% 95.0% 95.9% 95.4% 94.8% 95.3%Moorfields Eye Hospital 99.0% 97.3% 96.2% 99.1% 97.2% 98.9% 98.5% 98.7% 98.0% 98.3% 98.7% 98.0% 98.4%UCLH 95.4% 95.3% 96.6% 96.1% 95.2% 95.2% 96.3% 96.0% 96.0% 95.4% 94.4% 93.3% 95.2%Royal Free Hospital 97.6% 97.4% 98.1% 98.5% 99.2% 95.7% 98.2% 98.7% 98.4% 97.6% 96.6% 96.9% 97.6%Barnet & Chase Farm 95.6% 95.2% 95.1% 97.0% 97.3% 97.5% 92.4% 94.1% 96.0% 94.2%Guy's and St. Thomas' 96.2% 96.2% 96.1% 96.7% 95.8% 95.9% 96.0% 97.0% 96.7% 96.9% 96.2% 96.7% 96.6%St. George's Healthcare 94.9% 94.2% 94.9% 96.1% 94.9% 97.1% 96.3% 96.4% 97.3% 97.3% 96.6% 96.8% 96.8%

Feb-14 Mar-14 Apr-14 May-14Theme KPI / Measure Provider Jun-14Oct-13 Nov-13 Dec-13 Aug-14 Oct-14 Nov-14

Qua

lity

MRSA reported infections Zero tolerance

Sep-14Jan-14 Jul-14

C. Difficile reported infections

Mixed Sex Accommodation (MSA)

(Number of breaches)

Zero tolerance

VTE(% admitted patients assessed

for VTE risk)95%

2014-15YTD

2014-15 Target

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Date of meeting January 27 2015 H

Agenda item 2.5

Title of report: Healthwatch Report

Author(s): Dianne Barham, Chief Executive, Healthwatch Tower Hamlets


Dianne Barham, Chief Executive, Healthwatch Tower Hamlets

Ellie Hobart – Tower Hamlets CCG

Executive summary

The presentation sets out the key themes from the patient experience and feedback gathered by Healthwatch in 2014. Health and social care seems to be anything but patient centred. Patients are bearing the brunt of:

• over demand on GP practices which makes it difficult to see a GP or see the same GP

• poor administrative systems and processes that mean that appointments are often delayed, wrong, impossible to change or never happen.

• clinics running late, consultants not having test results or patient files

• planned surgery being postponed and cancelled • poor or delayed discharge • home care being disjointed and unreliable

It is worth noting that patients very rarely complain about the quality of clinical care, it is the processes and systems that they feel are letting them down.

Recommendation

Information x Approval To note Decision

Healthwatch is asking the CCG to work with us on our priorities 1. Improve the patient journey through primary and acute care. 2. Support older people living independently - integrated care and community health

services. 3. Improve access to GP surgeries 4. Engage the voluntary and community sector in providing community intelligence 5. Promote co-production of mental health services. 6. Promote good youth mental health

Conflicts of Interest • NA

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Key issues Healthwatch is asking the CCG to work with them on their priorities to:

1. Improve the patient experience – by promoting greater patient feedback, looking more closely at the patient journey to identify the key points where things go wrong, holding Barts to account for promised improvements.

2. Support older people living independently - integrated care and community health services. - engaging local patients and the public in designing, commissioning and delivering CHS and the development of a patient centred integrated care service.

3. Access to GP surgeries – enabling the public to influence the changes to primary care in the next 5 years to ensure they reflect the needs and priorities of the Tower Hamlets community.

4. Engage the voluntary and community sector in providing community intelligence to feed into the JSNA, CCG commissioning intentions and the HWS

5. Promoting co-production of mental health services. 6. Promote good mental health of young people

Report history This report summarises key themes that have emerged from the patient and user views gathered by Healthwatch Tower Hamlets during 2013-2014. A full version of the feedback report or the database of comments can be requested from [email protected]


Patient and Public views were gathered through the following activities:

Barts Health Patient Voices Project: This project was designed to enable local community groups to collect patient feedback on Barts Health services and involved the following community groups: Limehouse Welfare Association, Tower Hamlets Friends and Neighbours, Collective of Bangladeshi School Governors, Stepney Wisdom Group and Globe Wisdom Group - Social Action for Health, Stifford Centre, Deaf Plus and East London Vision. Enter and View visits (12), general outreach at community events and gathering points, Members’ feedback via attendance at Advisory Group and other Healthwatch meetings, Responses to online questionnaires, people who phone or come into the office for information and signposting to services.

The report has been agreed by the Healthwatch Board and the Healthwatch Advisory Group both of which are made up of patients and members of the public.


Link to BAF risk 4.1: Support local people and stakeholders to have a greater influence on services we commission and develop a responsive and learning commissioning organisation


One of the aims of the community intelligence gathering bursary will be to identify gaps in our knowledge of the needs of seldom groups in our

88

community and to give priority to projects who aim to fill those gaps.


Next steps Healthwatch has invited key stakeholders to an event to:

• Review Healthwatch Tower Hamlets priorities for the coming year and consider how, by working better together, we can ensure we have an impact on service commissioning, design and delivery.

• Consider how the community intelligence (Big Data) that we are gathering at a Tower Hamlets level can be utilised by our stakeholder partners to shape programmes and create positive social impact on the health of the Borough.

• Consider the development of a Community Intelligence Grant Programme for the voluntary and community sector.

• Launch the Healthwatch Tower Hamlets Feedback Centre and consider how it can be promoted and used effectively. The Feedback Centre is already live at www.healthwatchtowerhamlets.co.uk and will be promoted through a Borough wide street side poster campaign throughout February.

9:30– 1:00 Friday 6 February 2015 Room 5 Education Centre

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http://www.healthwatchtowerhamlets.co.uk/

CCG Governing Body Dianne Barham January 2015

High Level Engagement Summary 2014

91

Communications & Engagement Co-ordinator

Research analyst (new post) VCS Health and Wellbeing Forum grants programme. Volunteers, students.

Engagement Strategy

Project Manager working closely with VCS .

Chief Executive – making sure we have an impact

Influence stakeholders

Priority projects engaging with patients and community on key

areas, E&V

Community intelligence gathering Specific issues/areas/target groups

Day to day communication Outreach - awareness raising, signposting,

comment collecting. Website feedback

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Healthwatch in numbers

Healthwatch members 1389

Consultation and engagement events 39

Volunteers 92

People receiving information and signposting 68

Enter and View visits 32

Comments collected 1986

Reports produced 11

Reports to Healthwatch England 2

Issues to CQC and HWE 4

93

How we have gathered feedback in 2014 Barts Health Patient Voices Project: designed to enable local community groups to collect patient feedback on Barts Health services and involving: Limehouse Welfare Association, Tower Hamlets Friends and Neighbours, Collective of Bangladeshi School Governors, Stepney and the Globe Wisdom Groups, Stifford Centre, Deaf Plus, East London Vision.

Voice of Housebound residents: Tower Hamlets Friends and Neighbours

Enter and View visits A&E, Diabetes Centre, Foot Health Clinic, Whitechapel Dental, Abbey Dental, Globe Town Surgery, Harford Health Centre, The Wapping Group Practice, Health E1, Crisis House, Pritchard’s Road Day Centre, Mind in Tower Hamlets

Event feedback and comment collection 94

Difficulty in accessing routine appointments, asked to phone every morning at 8:30 or queue outside. Difficult if you work. Patient with a persistent cough did not go as a result.

Inconsistency across practices, one size doesn't fit all.

Some improvement but frequent changes add to confusion: triage & phone back, online, phone first, queue outside, walk in. Some patients being told to go to A&E if it’s urgent or taking themselves there.

Patient journey getting a GP appointment

95

Letters- wrong dates, wrong person, multiple letters different dates and times, no information on what appointments for, stating appointments have been missed patients were unaware of, conflicting text messages. Patient received 2 letters for different appt dates, 1 for a procedure she had already had, in 1 envelope sent to her parents address, where she does not live .

Hard to change appointments– particularly Mile End. - physiotherapy, foot health, ENT. Patients then DNA & referred back to GP. Appointments postponed, cancelled multiple times Long delays with orthopaedics, plastic surgery, dentistry Patient told his heart condition meant he was unlikely to survive 5 years but his appointment postponed for 12 months.

Patient journey getting a referral

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Patient transport turning up late so appointments are missed sometimes on multiple occasions, resulting in long delays or inadequate treatment.

Turning up for outpatients appointments to: • face long waiting times • be told that it’s been cancelled. • lost notes/files or lack of test results make the appointment pointless.

Cancelled procedures • plastic surgery cancelled frequently, one patient had

been scheduled for surgery 4 times, once was cancelled after she’s been put under aesthetic. patient who had lung cancer cancelled on day of surgery, second time it had occurred

Patient journey hospital

97

• Perception in some areas of staff being too few, being unhelpful, uncaring and unwilling to signpost.

• Sense that staff are equally frustrated with admin problems & are taking frustration out on patients.

• Particular issue with receptionists across providers. • Quality and availability of interpreters • Lack of training re vision/hearing impaired. She did not introduce herself or ask how I was feeling at any stage. She did not explain why I had to be connected to the monitor for so long which prevented me from sleeping. She laughed at my birth plan and when I asked for toilet paper at 2am she said 'That’s not my job'.

Patient journey staff attitude

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Wrong information on letters, info not in lay terms or no information e.g. GP integrated care letter Co-ordination of information for patients particularly long-term conditions Communication between departments, to GPs and different service providers delaying treatment. Lack of consistency within a patient’s journey often leading to unfulfilled expectations. I went to have my first ever breast screen in June 2014. The receptionist looked like she didn’t want to be at work, there was no hello, all she said was ‘take a seat’. I waited for 40 mins after my appointment time and when I got called, all the nurse said was, ‘Take off your upper clothing and come and stand here’, no explanation of what was going and what she will do. I had to ask my daughter to ask what are they going to do, even then the nurse said, ‘your mother needs to stand here and I will use the machine to screen her breast’.

Patient journey information & expectations

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• Older people confused by the seemingly endless stream of people coming to their home. Feeling they’ve lost control of their lives which in turn can lead to a mistrust of health professionals

• I feel like I’m just a set of tasks, home carers often only do ‘what they have time for’ not what’s needed

• Lack of cohesion between services • Changes of support packages and services is confusing,

reablement, virtual ward, integrated care. Sometimes involves changing carers who they are used to.

Now I have so many people coming in and out to see me, doctors, nurses, social workers, it is getting confusing – they all just tell me what to do

Patient journey treating the whole person

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1. Improving the patient journey – promoting feedback centre

2. Older people living independently - integrated care, adult social care and community health services.

3. Access to GP surgeries

4. Promoting co-production of mental health services.

5. Young people and mental health

Healthwatch priorities for next 12 months

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Dianne Barham Room 12, Block 1 Mile End Hospital, Bancroft Road, London E1 4DG Office: 020 8223 8922 Direct: 020 8223 8933 Freephone: 0800 145 5343 Email: [email protected] Web: www.healthwatchtowerhamlets.co.uk)

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http://www.healthwatchtowerhamlets.co.uk/


Date of meeting 27 January 2015 I

Agenda item 3.1

Title of report: 2015/16 Allocations

Author(s): Henry Black – Chief Finance Officer


Henry Black – Chief Finance Officer

Executive summary

The paper seeks to advise the Governing Body of the CCG’s allocation for 2015/16 and any changes to the previously announced allocation. It will also provide comparisons with other CCGs in London for illustrative purposes.

The headlines for Tower Hamlets CCG are as follows;

- Programme allocation for 15/16 - £335.9m - Administration (Running Cost Allowance) - £6.178m - The programme allocation includes the seasonal resilience

recurrent allocation of £1.792m but does not include BCF of £6.714m, which will be paid to CCG’s in addition to the programme allocation.

Recommendation


To note the content of the report, and discuss any actions required

Key issues - ‘Floor’ growth is reduced from the expected 1.7% (as announced in December 2013) to 1.4% as a result of the revised GDP deflator.

- Demographic growth in Tower Hamlets is projected to be 2.34%. Allocation per head is therefore 0.92% lower in real terms in 15/16 than the equivalent figure in 14/15

- The baseline now includes an allocation for seasonal resilience previsouly issued non-recurrentoy in year. However, the amount allocated to THCCG (£1.792m) is approximately £4m lower than the total in year non-recurrent money received for a similar purpose in 14/15.

Conflicts of Interest There are no identified conflicts of interests.

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Report history n/a


N/A


Addresses several corporate objectives, those around finance, ensures the governance body is sighted on key finance and performance targets:

Strategic Objective 3: Creating a thriving and stable health and social care economy

Strategic objective 4: Delivering against our statutory duties.


N/A



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2015-16 CCG Allocations

Executive Summary

CCG allocations for 2015/16 were confirmed at the NHSE Board meeting on 17th December 2014. Indicative allocations for 15/16 had originally been published in December 2013 as part of a two-year settlement. This paper seeks to advise the Governing Body of the CCG’s allocation for 2015/16 and any changes to the previously announced allocation. It will also provide comparisons with other CCGs in London for illustrative purposes.

The headlines for Tower Hamlets CCG are as follows;

- Programme allocation for 15/16 - £335.9m - Administration (Running Cost Allowance) - £6.178m - The programme allocation includes the seasonal resilience recurrent allocation of

£1.792m but does not include BCF of £6.714m, which will be paid to CCG’s in addition to the programme allocation.

- ‘Floor’ growth is reduced from the expected 1.7% (as announced in December 2013) to 1.4% as a result of the revised GDP deflator.

- Demographic growth in Tower Hamlets is projected to be 2.34%. - Allocation per head is therefore 0.92% lower in real terms in 15/16 than the

equivalent figure in 14/15 THCCG Allocation Summary The table below provides the summary financial figures making up the 15/16 allocation: 2014/15 adjusted baseline £329,546 Core Growth £4,602 Seasonal Resilience Funding Included in Baseline £1,792 Total Growth £6,394 2015/16 Opening Allocation £335,940 Target Allocation £331,224 Distance from target 1.42% Table 1: THCCG Allocation Summary

NHSE Allocations Process, 2015/16 Included within the overall allocations is £1.98bn of additional investment in health spending, as announced in the autumn statement. The funding formula for CCGs used to

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derive 15/15 allocations is the same as that adopted by the NHS England Board in December 2013, which includes a specific 10% adjustment for unmet need and inequalities, alongside the equivalent 15% adjustment for primary care. NHS England have established three principles for the £1.1bn of additional programme funding to CCGs on top of the previously published allocations for 2015/16:

- Firstly, no CCG should receive less funding in cash terms than was previously agreed in December 2013 to be allocated in 2015/16 (other than any recurrent baseline changes agreed in 2014/15);

- Secondly, all CCGs should receive at least real terms growth (1.4%, the revised GDP deflator) and their fair share of the now recurrent £350m resilience funding for CCGs on their recurrent baseline; and

- Thirdly, the remaining funding should be applied to accelerate the pace of change towards target allocations and in particular reduce the number of CCGs significantly under target.

Because Tower Hamlets is deemed to be above target according to this formula, the CCG does not therefore qualify for additional growth over and above the floor 1.4%. It should be noted that the rate of projected demographic growth in Tower Hamlets (2.34%) is in excess of normalised floor funding uplift of 1.4%. The CCG allocation formula does not automatically uplift allocations in respect of demographic growth, other than for CCGs who are below target. The funding formula generates a target allocation per capita, which is then multiplied by projected population to derive a total target allocation. If the target allocation is higher than actual current allocation then the CCG will qualify for additional growth. This may occur as a result of historic under funding, high demographic growth or a combination of the two. If the target allocation is lower than actual current allocation then the CCG will receive floor growth only, and no additional uplift regardless of the underlying rate of demographic growth. As stated above, the key aims of the allocation policy are to reduce historic distance from target, whilst ensuring that all CCGs receive a real cash increase. It does not explicitly provide resource in relation to demographic growth other than to the extent that this affects CCGs which are close to or below target. This means that, despite receiving a real cash increase in baseline allocation of 1.4%, or £4.6m, the impact in Tower Hamlets of high demographic growth results in a real cash reduction in allocation per head of 0.92%, from £1,153 per head in 2014/15 to £1,142 per head in 15/16. CCG Allocation Analysis Please see the below tables, which seek to analyse the position of Tower Hamlets in relation to other CCGs in London.

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Table 2 shows all London CCGs ranked in order of ‘target’ allocation per capita. The CCG allocation formula determines that Islington has the highest weighted need in the capital, at £1,256 per head, and Wandsworth has the lowest at £972 per head. THCCG is ranked 14th of 32, at £1,113 per head which is around 12.9% lower than Islington, and for comparison is 2.3% lower than City & Hackney, 3.1% higher than Waltham Forest and 6.2% higher than Newham.

Table 2: All London CCG Per Capita Allocation Targets

2015/16

RankPer Capita

Closing Target

1 NHS Islington CCG 1,2562 NHS Lewisham CCG 1,2253 NHS Havering CCG 1,2024 NHS Greenwich CCG 1,2005 NHS Bromley CCG 1,1996 NHS Sutton CCG 1,1897 NHS Bexley CCG 1,1818 NHS Southwark CCG 1,1679 NHS Barking & Dagenham CCG 1,152

10 NHS Croydon CCG 1,15211 NHS Enfield CCG 1,14212 NHS City and Hackney CCG 1,13913 NHS Lambeth CCG 1,13914 NHS Tower Hamlets CCG 1,11315 NHS Hounslow CCG 1,09416 NHS Hammersmith and Fulham CCG 1,09217 NHS Camden CCG 1,09118 NHS Ealing CCG 1,09019 NHS Barnet CCG 1,08120 NHS Hillingdon CCG 1,08121 NHS Haringey CCG 1,08022 NHS Waltham Forest CCG 1,07823 NHS West London (K&C & QPP) CCG 1,07824 NHS Redbridge CCG 1,06925 NHS Newham CCG 1,04426 NHS Harrow CCG 1,03427 NHS Merton CCG 1,03028 NHS Kingston CCG 1,00729 NHS Richmond CCG 1,00530 NHS Brent CCG 99931 NHS Central London (Westminster) CCG 99732 NHS Wandsworth CCG 972

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Table 3 shows the impact of high demographic growth on allocation per head, and demonstrates the adverse effect on Tower Hamlets which, as a result of being over target receives the lowest (negative) growth per capitation in London and, indeed, in the whole country. Selected for illustrative purposes

Core Per capita growth

Rank

NHS Hounslow CCG 5.44% 1 NHS Harrow CCG 5.44% 2 NHS Bromley CCG 5.44% 3 NHS Croydon CCG 5.44% 4 NHS Hillingdon CCG 5.38% 5 --------------------------------- ------------ ------ NHS City and Hackney CCG 0.23% 26 NHS Newham CCG 0.22% 27 NHS Wandsworth CCG 0.21% 28 NHS Islington CCG -0.31% 29 NHS Central London (Westminster) CCG -0.43% 30 NHS Camden CCG -0.48% 31 NHS Tower Hamlets CCG -0.92% 32 Table 3: Relative Growth Per Capita

This disparity, caused principally by demographic growth, between relative resources and in-year uplift is further illustrated by table 4, which shows the movement in normalised (core allocation, excluding seasonal resilience) relative to opening distance from target. This shows that, despite being substantially further above target than Tower Hamlets, the top three CCGs listed all received small growth, with Tower Hamlets one of only 4 CCGs in London to suffer a reduction in per capita funding.

Table 3: DfT v Per capita growth

Selected for illustrative purposes Distance from target Per Capita Growth

NHS West London (K&C & QPP) CCGNHS Hammersmith and Fulham CCGNHS Wandsworth CCGNHS Tower Hamlets CCGNHS Havering CCGNHS Barnet CCGNHS Hillingdon CCGNHS Harrow CCGNHS Bromley CCGNHS Croydon CCGNHS Hounslow CCG

Under Over -ve | +ve

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Financial Risks for 2015/16 In summary, the overall effect of the above means that THCCG faces substantial financial risks from the following factors:

1. The high level of demographic growth for which no additional allocation is provided 2. The CCG funding formula allows an additional factor of up to 10% in respect of

unmet need and inequalities. It is not clear how effectively this accounts for the specific issues of deprivation in Tower Hamlets, and how these issues manifest themselves in the form of demand for healthcare.

3. Seasonal resilience funding, which in 2014/15 was provided centrally by NHSE is reduced from a non-recurrent sum of around £4.2m to a recurrent sum of £1.8m.

4. In addition to OR, THCCG received non-recurrent RTT support of £1.7m. Planning guidance requires us to assume that the increased baseline sum of £1.8m is the total we should expect to receive, resulting in a further cost pressure to the system of £4.1m.

The full implications of the above are still being worked through, and further analysis will be provided to the Governing Body in future meetings. However, what is clear is that ensuring future delivery of financial surplus will require substantial response in terms of delivery of QIPP across the CCG’s programme of activities. Recommendations The Governing Body is asked to note the contents of this report, and make any comments on the CCG response.

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Date of meeting 27th January 2015 J,K,L,M,N,O

Agenda item 3.2

Title of report: Primary Care Co-Commissioning Application, Process and Update

Author(s): Genevieve Okoro – Transformation Manager – Tower Hamlets CCG

Presented by:

Sponsor (if different): For further information

Jane Milligan – Chief Officer – Tower Hamlets CCG / Rahima Miah – Lead for Transformation – Tower Hamlets CCG

Jane Milligan – Chief Officer – Tower Hamlets CCG – [email protected]

Executive summary

• NHS Tower Hamlets CCG applied to take on delegated commissioning responsibility for Primary Care (GP Services) from NHS England.

• As part of our application, which was submitted on 9th January 2015, we attached draft governance documents which were developed in consultation with constituents and stakeholders.

• NHS England have asked that all governance documents are approved by the CCG Governing Body before the end of January 2015. Should our application be approved by the regional moderation process on 16th January 2014, approval of governance documents at the CCG Governing Body will be one of the stipulations.

• The purpose of this report is to update the Governing Body on the proposal that was submitted to NHS England on 9th January and for the Governing Body to approve all of the draft governance documents which were used as supporting documentation as part of the submission.

Recommendation


the Governing Body are asked to approve the;

• Terms of Reference for the Primary Care Committee

• Amended CCG Scheme of Delegation

• Model Delegation from NHS England

• Amended CCG Constitution

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• Conflicts of Interest Policy

They are also being asked to note the next steps and timescales for co-commissioning.

Conflicts of Interest • The CCG is asked to approve the structure of delegated Commissioning arrangements in Primary Care subject to NHSE approval of our application for delegated commissioning arrangements

• There are no conflicts of interests in this instance, though we are mindful of this happening during the implementation phase of co-commissioning and so have amended our conflicts of interest policy to reflect this – this is attached

Key issues NHSE wrote to all CCGs inviting expressions of interest (EOI) from CCGs to work more closely with NHSE and other CCGs in commissioning general practice. TH CCG submitted a formal EOI in collaboration with Waltham Forest and Newham CCGs on 20th June 2014 with the aim of some implementation during 14/15 and more complete co-commissioning for 15/16. WELC CCGs agreed to work together to develop a model for co commissioning activities with NHSE (both shared and independent), this development is integral to achievement of local CCG / Borough priorities and shared wider objectives such as 5 year strategic plans, Transforming Services Together (TST) and Integrated Care.

In Tower Hamlets we have always strived to develop and support a sustainable primary care system that contributes to our plans to improve health outcomes and develop an integrated healthcare system. In July 2014 we submitted an expression of interest outlining our intention to become Primary Care Co-commissioners. In November 2014 further guidance was released by NHS England, inviting CCGs to submit proposals for co-commissioning. CCGs were allowed to choose between three types of co-commissioning arrangements, which were as follows:

Level 1 – Greater involvement in Primary Care decision making: CCGs who wish to have greater involvement in primary care decision making could participate in discussions about all areas of primary care including primary medical care, eye health, dental and community pharmacy services, provided that NHS England retains its statutory decision-making responsibilities and there is appropriate involvement of local professional networks

Level 2 – Joint Commissioning: A joint commissioning model enables one or more CCGs to assume responsibility for jointly commissioning primary medical services with their area team, either through a joint committee or “committees in common”. Joint commissioning arrangements give CCGs and area teams an opportunity to more effectively plan and improve the provision of out-of hospital services for the benefit of patients and local populations

Level 3 – Delegated Commissioning: Delegated commissioning offers an opportunity for CCGs to assume full responsibility for commissioning general practice services. Legally, NHS England retains the residual liability for the performance of primary medical care

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commissioning. Therefore, NHS England will require robust assurance that its statutory functions are being discharged effectively. Naturally, CCGs continue to remain responsible for discharging their own statutory duties, for instance, in relation to quality, financial resources and public participation

Tower Hamlets CCG submitted proposals related to delegated commissioning. The opportunity to become primary care delegated commissioners will provide us with greater strategic oversight and the opportunity to shape the way in which primary care develops. Our intention is to act collaboratively across Waltham Forest, Tower Hamlets and Newham (WEL) and work towards the aims set out in the Strategic Commissioning Framework for Primary Care Transformation in London.

The deadline for submitting our proposal to become primary care delegated commissioners to NHS England was 9th January 2015. Our proposal set out plans to operate as primary care delegated commissioners from April 2015, with delegated authority passing direct to each of the three CCGs in WEL. In order to become primary care delegated commissioners, we will need to make some changes to our constitution and also establish a Primary Care Committee to oversee primary care delegated commissioning. Our delegated powers for primary care will pass down from NHS England to the CCG governing body, where the governing body will form a sub-committee with a lay and executive majority to make decisions on primary care. The functions being delegated by NHS England, and by which the Committee will make decisions upon are as follows:

• 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)

• Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”)

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF)

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

• Approving practice mergers; and

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

We have been provided with some model wording for the constitution, and the terms of reference for the Primary Care Committee, which have been developed by solicitors on behalf of NHS England. The model wording enables us to act as primary care delegated commissioners. This model wording has been reviewed internally by all of the WEL CCGs and our view is that, subject to the minor amendments you will see highlighted in the documents in red, the model wording should be adopted as it stands to ensure that we are in line with national changes relating to co-commissioning. In addition, in preparation for our new role, we have been asked to update our

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Conflicts of Interest policy to reflect statutory guidance produced by NHS England on 18th December 2014 and to include the Primary Care Committee in the CCG scheme of delegation, reflecting that we will need to update our constitution in preparation for our new responsibility.

Therefore, the Governing Body are asked to approve the Tower Hamlets CCG Primary Care Committee;

• Terms of Reference for the Primary Care Committee

• Amended CCG Scheme of Delegation

• Model Delegation from NHS England

• Amended CCG Constitution

• Conflicts of Interest Policy

Following the approval of these documents, we will establish the Primary Care Committee so that it the first meeting is April 2015. We will put in place the structures for the Committee, along with carrying out further transfer due diligence from NHS England.

Report history This report was presented at Governing Body Organisational Development Session by Rahima Miah, Transformation Lead and Justin Phillips, Governance and Risk Manager on 6th January 2015.


This issue has been discussed at the following events:

• Healthwatch Advisory Group Meeting (16/12/2014)

• Monthly Networking Leads Meeting (6/01/2015)

• Governing body OD session which (6/01/2015)

• GP Forum Inc. LMC (4/11/2014)

• Tower Hamlets Health and Wellbeing Board (13/01/2015)

• Meeting with LMC (13/01/2015)

There are plans to continue to engage with these stakeholders for ongoing involvement and development of co-commissioning in Tower Hamlets and across WEL from now until the end of March 2015.


N/A


Monitoring and actively improving the performance and quality of Primary Care service provision will have a beneficial impact for all patients in Tower Hamlets.

Resource requirements It is not yet known what additional resources will be required to implement this recommendation. Should our application be successful, we will undertake a due diligence process ahead of the transfer of

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finances and responsibilities from NHSE to the CCG.

The outcome of this will inform the resource needs.

Next steps • Continue to refine local and WEL primary care governance arrangements.

• Agree composition of the local Primary Care Committee and recruit additional members.

• Undertake due diligence process, ahead of the transfer of finances and responsibilities from NHS England to the CCG.

• Agree primary care co-commissioning strategy and priorities for 2015/16 and beyond.

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WEL Primary Care Co-commissioning Proposal

19 January 2015

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Overview of Proposal • Waltham Forest and East London (WEL) has a history of working together,

most recently through the Transforming Services Together agenda, which is our programme to deliver the 5-year Strategy Plan for our health economy

• We have joint strategies across the CCGs within WEL (Tower Hamlets, Newham and Waltham Forest) and we wish to take the opportunity presented by co-commissioning to enable the delivery of the primary care workstream of the TST programme

• At the heart of our proposal is the desire to make local decisions about primary care services for our population, but to also maximise the potential of carrying out the activities related to primary care commissioning at scale

• In our proposal we will seek to establish borough based Primary Care Committees, with decisions taking place at borough following recommendations from a WEL Collaborative Committee.

• Our proposal is the outcome of a series of engagement meetings across WEL as individual CCGs with our stakeholder groups and collectively as three CCGs working together.

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What are the benefits to WEL of becoming co-commissioners?

• Through co-commissioning we want to localise decisions about primary care, integrating services for patients, ensuring we make local decisions about the way we use our estate and how we work with our local authority to ensure a high quality service for patients

• By being close to our local population, through our links with our HWBB and our patient and voluntary sector groups, we are best placed to understand our patients views on how we shape the future of primary care. Therefore are better able to commission in a way that reflects the needs of local people

• We have an ambitious programme of work through our Transforming Services Together programme that cannot be achieved without integration of services across care providers, we see co-commissioning as one of the vehicles to enabling us to deliver our strategic aims across WEL

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WEL Achievements in Primary Care

• WEL has a strong track record of delivery in primary care both in terms of health outcomes and innovation in primary care delivery including:

• The development of Networks in Tower Hamlets enabling practices to work together to achieve improved outcomes for example in diabetes and childhood immunisation;

• The development of Multidisciplinary Teams of GPs and diabetes specialists in Newham to establish a system of primary care diabetes management that has achieved improved outcomes among the best in London;

• Waltham Forest have engaged GPs in care planning supporting the integrated care programme with the support of the Health Analytics risk stratification tool

• In WEL we have primary care commissioning experience in each of our CCGs including Executive level staff who have lead the development and contracting of Primary Care in PCTs and PCT Clusters and GPs who have performed Medical Advisor roles in PCTs and Lay Members who have been involved in PCT decision making groups

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WEL Achievements in Primary Care

Further examples of achievements in WEL in commissioning of primary care: • Micro-teams in Tower Hamlets – A clinical system design. Focuses on pulling practice staff

into teams, they then have a set of patients they look after consistently. The goal is to increase continuity of care as well as demand and access management; it also has an important role in delivering continuity of care. This is being piloted currently within 5 practices.

• Online Self Care & GP Consultations - The online self-care and GP Consultations model is a programme to connect all Tower Hamlets residents to online services, including a symptom checker, self-care, sign-posting, 24/7 nurse and pharmacy advice and e-consults with a patient’s own GP.

• Innovation fund- Practices in Tower Hamlets are leading pilot schemes to address demand at practice level.

• GPs in Waltham Forest can now test for heart failure using B-type Natriuretic Peptide (BNP) testing, savings patients a trip to hospital

• Newham and Tower Hamlets practices with CCG support achieved the best and the second best levels of immunisation across the flu programme in 13-14 and are set to equal this in 14-15

• The CCGs work with the Clinical Effectiveness Group at QMW university to collect and review quality and outcomes data from GP systems that has facilitated high performance in outcomes in the management of long term conditions

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What are the benefits to WEL of becoming co-commissioners?

• We want to work together as a group of CCGs to support practices to maximise the delivery of transformation and achieve the specifications within the London Strategic GP Commissioning Framework, which will improve access, proactive care and co-ordination of care.

• Through creating greater integration within WEL for services and through using new contract mechanisms to encourage population based contracting models, we will clinically commission high quality services, identify long term conditions earlier and promote self-care

• We will be able to have a greater emphasis on our primary care workforce, ensuring that we address local workforce needs, retaining our best staff and develop the staff we have ensuring a greater clinician to patient ratio and greater continuity of care and satisfaction for patients.

• We feel that patients will see an improvement in outcomes, reduced inequalities and an increase in satisfaction with the services provided in primary care

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Consideration of risks and opportunities of co-commissioning for WEL?

Risks Mitigation Opportunity Perceived COI in relation to

commissioning of services from member practices

Robust governance arrangements with recommendations being provided by

the WEL Collaborative Forum. TOR and membership of Committee ensures

that COI risk reduced

Opportunity to make local decisions about how services for primary care

are commissioned through transparent and robust governance arrangements

Staff resources from NHS England may not be enough once devolved

Core contracting staff to remain as a central team for year 1. Review of tasks

vs roles in year 1 in preparation for greater devolution of staffing in year 2.

Local approach to staffing with an emphasis on WEL wide staffing for

economies of scale

CCG will need to engage on primary care commissioning issues which will

be resource intensive

CCG have existing arrangements in place for engaging local people and are

best placed to do so. This will make cross pathway engagement simpler and

more meaningful

Brings greater meaning to engagement about out of hospital care for local

people as the CCG will have responsibility for all of the portfolio

areas

Additional funding to primary care may create pressure on other CCG

commissioned areas

The CCG continues to take decisions based on local need and priorities and

will ensure that decisions on investment continue to occur in a fair and transparent manner in line with

the needs of the local population and in consultation with the CCGs

stakeholder engagement groups

Local and not central determination of investment should align funding to the areas of greatest priority and need for local people. Development of locally

designed incentive schemes tailored to the needs of the local population.

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Our proposed approach – 2015/16 • For year 1 of our new role we will make decisions about primary care with

individual CCG Primary Care Committees • The CCG Committees will be supported by a WEL Collaborative Committee

which will make recommendations to CCG Primary Care committees on the outcome of procurement processes and contract performance management decisions

• We will make use of the economies of scale through sharing staff resources (i.e. NHS England central contracts team and WEL TST Programme team)

• Our aim for 2015/16 is to adopt a steady state for the transfer of decisions and financial responsibility, ensuring we have the ability to transition in to our new role and maximise the opportunities of bringing commissioning together. Therefore, we do not intend to make any changes (additions to, or reductions) to the primary care budget for our boroughs, nor to carry out any pooling for year one.

• We will continue to carry out WEL wide strategic primary care work through the TST programme, ensuring that we continue to collaborate and to share learning across our boroughs, maximising the benefits of working at scale within a strategic framework managed by the WEL Collaborative Committee.

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Delegation of responsibilities from NHS England in 2015/16

NHS England

CCG Governing Body

CCG Primary Care Committee (x3)

Delegation of responsibility for

Primary Care Commissioning

CCG decision making

Committees

WEL Collaborative Committee

Makes recommendations on designated areas of Primary Care

Commissioning supporting the three WEL Primary Care Committees –

decisions are made by CCG Committees

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Role of the Committee and Collaborative Forum

CCG Primary Care Committee


NHS England delegates to CCG to make decisions on (decisions made by Primary Care Committee): • GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of

contracts, taking contractual action such as issuing breach/remedial notices, and removing a contract

• Newly designed enhanced services (local Enhanced Services” and Directed Enhanced Services); • Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); • Decision making on whether to establish new GP practices in an area; • Approving practice mergers • Decisions on the management of practice vacancies including whether to disperse, close or procure • Making policy decisions on ‘discretionary’ payment (e.g., returner/retainer schemes)

Areas that the WEL Collaborative Committee may make recommendations upon: • Recommendations on case by case basis whether a contractual sanction should be taken on a

primary medical services contract where a breach may have occurred • Recommend what the specific contractual sanction should be when breach of contract has occurred • Recommend outcome of an appeal made by a practice relating to DES, QOF, core contract or

discretionary payments • Recommend requests for contract mergers • Recommend making on award of contract when there is a tender process for a primary medical

service contract (APMS, PMS, GMS) • Recommend what discretionary payments for premises (legal fees, project costs relating to

moves/major refurbishment), capital schemes, business cases for new premises or major refurbishment

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Example of how delegated commissioning would work in WEL Decision for Practice list to be released for

procurement

CCG leads work with local stakeholders to develop specification for new practice (PPGs, Health Watch,

LMC and HWBB etc)

Co-commissioning senior manager reviews technical aspects of the specification

and provides feedback

CSU provides procurement advice and

releases procurement PQQ, ITT to bidders

Responses from bidders scored by WEL Collaborative

Committee against scoring criteria

WEL Collaborative Committee make

RECOMMENDATION on preferred bidder to CCG Primary Care Committee

CCG Primary Care Committee APPROVE

CCG Governing Body RATIFY decision of CCG

Primary Care Committee

CCG Primary Care Lead/

Team

Co-commissioner

s (NHS E)

CSU


CCG Primary Care

Committee

CCG Governing

Body

Contract let and managed by Central

Contracts Team (NHS E)

Central Contracts

Team (NHS E)

Co-commissioners liaise with colleagues at NHS E to

consult on proposed spec

CCG Primary Care Committee agrees final spec following feedback and send to CSU

Procurement

Bidder responses received

Note – The Primary Care Committee do not have to APPROVE the recommendations of the WEL Collaborative Forum and can ask for the forum to carry out additional actions before a recommendation can be APPROVED. A register of such actions will be kept to

ensure transparency of procurement decisions

Co-commissioning senior manager reviews the outcome of GB

RATIFICATION and notifies Central Contracts Team of required actions

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Carrying out tasks related to Primary Care Commissioning Teams – 2015/16

NHS England Central Contracts Team (50 x wte for London)

WEL Primary Care Programme Team

CCG Primary Care Teams (Borough structures as is in

immediate future)

In 2015/16 we will work with NHS England to share part of the Central Contracts Team resource,

however we do not intend to make any changes related to staff roles or employing organisation

until 2016/17

In 2015/16 our CCG staff will continue to support practices through primary care development activities. The WEL Primary Care

Programme Team will provide a link between the committee and NHS E and provide over-arching programme support for TST

initiatives related to Primary Care

NHS E Co-commissioning staff 1 x 8d and 1 x 8b

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Our proposed approach – 2016/17 • For year 2 we will seek to identify the scope for more functions

that can be carried out across the three boroughs to maximise economies of scale and use of expertise

• We will review the potential to have one Primary Care Committee for WEL in Jan 2016, changing the function of the WEL Collaborative Forum

• We will review the potential for pooling of financial resources, to support the TST primary care programme implementation including premises, workforce and integrated care initiatives

• We will identify how we ensure WEL population level improvements to service delivery via new forms of contracting with practices, through a review of QOF incentives and the need to commission an enhanced role for primary care in delivering integrated care

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Our leadership and management capacity to deliver the Primary Care transformation and co-commissioning in WEL

Steve Gilvin Primary Care SRO for WEL

Newham Accountable Officer

Jane Mehta Primary Care Executive lead for WEL

Waltham Forest

Primary Care Clinical Lead Tower Hamlets

Rahima Miah Transformation Lead Tower Hamlets CCG

Carl Edmonds Primary Care Lead

Manager Waltham Forest CCG

Mohsin Patel Primary Care Lead

Manager Newham CCG

Genevieve Okoro

Transformation Manager

Tower Hamlets CCG

Justin Phillips Primary Care Lead

for Governance Tower Hamlets

CCG

David Pearce Primary Care Lead for

Governance Waltham Forest CCG

4 x Primary Care Facilitators

Ashmeed Aziz Primary Care Lead

Officer Newham CCG

Vacant Co-commissioning Senior Manager NHS England

Attracta Asika Co-commissioning

Manager NHS England

David Sturgeon Director for Central Contracting Team

NHS England

Central Contracting Tean

50 x wte staff

WEL Primary Care Management Group Steve Gilvin (Chair), Jane Mehta (Vice Chair), Rahima Miah, Carl Edmonds, Mohsin Patel, Senior Co-commissioning Manager or deputy, David Sturgeon, Suman Barhaya, Daniel Morgan, Tony Hoolaghan,

Matt Duncan (Programme support for TST provided by Berkeley Partnership)

Suman Barhaya TST Programme

Manager for Primary Care Devt in WEL

NEL CSU

Tony Hoolaghan Programme Director support to WEL Co-

commissioning NEL CSU

Daniel Morgan Programme

Management support to WEL Co-

commissioning NEL CSU

Group already established to take forward co-commissioning plans. Group will change from the WEL Leads planning Group to the WEL Primary Care Management Group from April 2015. Currently meets weekly but will move to bi-weekly

from April.

Note – Other staff in WEL have a role in Primary Care Development, particularly where this work overlaps with work of our integrated care leads.

Jo-Ann Sheldon Contracts manager

Tower Hamlets CCG

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What tasks will the NHS England Central Contracts Team take on?

1 Strategic planning • Data analysis

2.1 Operational contracting and payments - GMS, PMS and APMS contracts • Monitoring of KPIs and income • Contract monitoring • Contract reviews • Contract action (breaches etc.) • Approval and authorisation of global

sum / equivalent • Payment of global sum • Responding to queries from

contractors on global sum payments • Preparation of annual payment

statement

2.5 Processing DES Appeals • Avoiding unplanned admissions DES • Minor surgery • Extended hours • Learning disabilities • Dementia

2.4 DES assessment and authorisation of claims • Minor surgery • Learning disabilities • Dementia

2.7 Discretionary payments • Development of policies • Assessment of claims

2.8 Payment of DES, QOF and

discretionary claims

2.6 QOF (national implementation) • Provision of guidance to practices • Assessment and authorisation of

achievement • Appeals management

3.1 Response to contract termination and resignation (includes branch closure) • Contingency planning • Patient and stakeholder engagement

plans • Development of communications

materials • Issue of patient letters • Management and issue of other

stakeholder communications • Response to patient and stakeholder

queries • Preparation of data to support

decision making on commissioner response

• Preparation of report for decision making groups/committees

• Decision on commissioner response • Support to practices for closure or

service transfer 8 Other

• Collaborative payments • Interpreting • Minor ailments scheme • Management of PCS agreements /

contracts • Health and justice services

Draft – further discussions to take place post Jan 15

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What tasks will the NHS England Central Contracts Team take on? (continued)

7 EPRR* • Responding to local service

disruption • Responding to major service

disruption • Planning for major service disruption • Flu pandemic planning • Other public health responses (e.g.

ebola) • Issuing communications to practices

6 Premises development* • Approval of DV rent reviews • Responding reimbursement appeals • Approval of discretionary payments

for SDLT, legal fees and development costs to practices

3.2 Response to request for contract mergers* • Development of communications

material • Issue of patient letters • Management and issue of other

stakeholder communications • Response to patient and

stakeholders queries • Preparation of data to support

decision making on commissioner response

• Preparation of reports for decision making groups/committees

• Decision on commissioner response • Support to practices for closure or

service transfer

4 Engagement and consultation* • Patient and public engagement on

service change and improvement • HSC reporting and accountability • HealthWatch reporting and

accountability • Responding to MP and local

councillor letters and queries • Management and response to patient

complaints

• Workforce audit (1.1) • Minor surgery (2.3.2) • Learning disabilities (2.3.5) • Dementia (2.3.6) • Immunisation and children’s services

(8.5)


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What tasks will the CCG Primary Care Team’s take on?

1 Strategic planning • Premises and infrastructure audits • Implementation of London

Framework • GP Provider Development –

organisation structures • Workforce development • Development of Strategic Primary

Care Premises Plan • Development of local contracting

models • Strategic plan development and

refresh

2.2 Local Enhanced Services (LES) • Design and development of LES • Approval of LES • Monitoring and reporting on LES • Assessment of LES achievement and

payment authorisation

2.9 Design of Local Incentive Schemes (as an alternative to QOF)

2.3 Directed Enhanced Services (DES) management and implementation • Avoiding unplanned admissions DES • Extended hours

2.4 DES assessment and authorisation of claims • Avoiding unplanned admissions DES • Extended hours


• Design of local aspects of PMS contracts (2.1.1)

• Design of of local aspects of APMS contracts(2.1.2)

6. Premises Schemes • Procurement of support for the

development of strategic business cases

• Approval of improvement grants <£100k p.a.

• Approval of capital schemes >£150k • Approval of business cases for new

premises / expansion >£100k

2.2 Operational contracting and payments - LES • Payment of claims

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What tasks will the NHS England Primary Care Programme Team (co-commissoners) take on?

Leadership and oversight • Working between NHS E and CCG

teams on management of issues arising

• Senior leadership on primary care issues for CCG and NHS E

Programme management • Programme reporting • Trajectory management • Analysis of BSC results and

coordination of action plans from boroughs

• Support to TST initiatives across WEL

Secretariat • Preparing and following up on

committee papers • Support to committee chair • Scheduling and publishing of papers • General secretariat duties

1 Strategic planning • Premises and infrastructure audits • Implementation of London

Framework • GP Provider Development –

organisation structures • Workforce development • Development of Strategic Primary

Care Premises Plan • Development of local contracting

models • Strategic plan development and

refresh


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About the CCG Primary Care Committee

• The Committee will have a non-GP majority in all CCGs with Lay Members, other Clinical Members and Executive majority

• We will invite our HWBB, LMC, Public Health Department and Healthwatch to nominate observers to the Committee

• We will ask that the HWBB member is a Local Authority rep • 1 vote will be afforded to each voting member, the chair will

have the second and deciding vote • The Committee will operate in accordance with the CCG

standing orders in the recently revised constitutions • We will review the TOR for the Committee annually • The Committee will meet in public monthly, with the first meeting

expected to take place in April, following Lay member recruitment and then induction

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Makeup and Quorum of the CCG Primary Care Committee’s in each of the boroughs

Waltham Forest Voting members: Lay chair (from CCG), Lay vice chair (from CCG), 2 x additional Lay members (recruited Feb – March), CCG Chief Finance Officer, CCG GP (Primary Care Lead), CCG Accountable Officer, Non-voting members: HWBB rep (LA member), Public Health rep, Health watch rep, LMC, 2 x additional CCG GPs, NHS England Representative The Committee will be Quorate with three of the seven voting members in attendance, with at least one Lay member present. Where the GP member has a conflict of interest they will be excluded from the agenda item discussion and decision.

Tower Hamlets Voting members: Lay chair (from CCG), Lay vice chair (from CCG), Board Nurse, Board Secondary Care Consultant, CCG Chief Finance Officer, Independent Clinical Adviser, CCG Accountable Officer Non-voting members: HWBB rep (LA member), Public Health rep, Health watch rep, LMC, 2 x additional CCG GPs, NHS England Representative The Committee will be Quorate with three of the seven voting members in attendance, with at least one Lay member present. Non-voting GP observers will be excluded from Committee discussions and decisions regarding topics where they have a conflict of interest.

Newham Voting members: Lay chair (from CCG), Lay vice chair (from CCG), Board Nurse, CCG Chief Finance Officer, CCG GP (Primary Care Lead), CCG Accountable Officer, Non-voting members: HWBB rep (LA member), Public Health rep, Health watch rep, LMC, 2 x additional CCG GPs, NHS England Representative The Committee will be Quorate with three of the six voting members in attendance, with at least one Lay member present. The voting GP or non-voting GP observers will be excluded from Committee discussions and decisions regarding topics where they have a conflict of interest. The Independent GP advisor to the WEL collaborative will be involved in those decisions where all of the local GPs are conflicted.

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About the WEL Collaborative Committee

• The Committee is not a decision-making body but has a key role in making recommendations to the CCG Primary Care Committees on specific contract issues

• The voting membership of the Committee will be composed of Lay and Executive members of CCG Boards

• The CCGs will appoint an Independent Medical Advisor to be a member of the committee and provide expert advice on Primary Medical Services and be a member of the committee

• A Lay member from each CCG will be a member of the committee and the committee will require a minimum of one member from each CCG to be quorate

• We will invite our HWBB, LMC, Public Health Department and Healthwatch to nominate observers to the Committee

• We will ask that the HWBB member is a Local Authority rep • 1 vote will be afforded to each voting member, the chair will have the

second and deciding vote • We will review the TOR for the Committee annually

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Makeup of the WEL Collaborative Forum and Quorum Voting members: Lay chair, Lay vice chair, additional Lay member (Three Lay members to be the Chair’s of each of the three Primary Care Committee’s) CCG Accountable Officer Newham CCG (SRO Primary Care), CCG Chief Finance Officer (Tower Hamlets CCG), CCG Governance Executive (Waltham Forest CCG), Independent Medical Advisor to be appointed by the CCGs Non-voting members: HWBB rep (LA member), Public Health rep, Healthwatch rep, LMC, 2 x additional CCG GPs, Primary Care Contracting representative, NHS England The Committee will be Quorate with 3 of the 7 voting members in attendance, with at least one needing to be a Lay member.

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Summary of engagement relating to co-commissioning across WEL?

Tower Hamlets Waltham Forest Newham • Monthly Networking Leads Meeting

(6/01/2015) • Governing body OD session which

Inc. HWBB representative and council members (6/01/2015)

• GP Forum Inc. LMC (4/11/2014) • Tower Hamlets Health and

Wellbeing Board (13/01/2015) • Meeting with LMC (13/01/2015)

• Waltham Forest Healthwatch (5/12/2014)

• Special board meeting (3/12/2014) • Chingford Locality Meeting

(3/12/2014) • Leyton/stone Locality meeting

(3/12/2014) • Primary Care Improvement Group

(17/12/2014) • Special CCG Members’ meeting

(18/12/2014) • Strategic Commissioning Staff

meeting (6/12/2014) • Waltham Forest Health and

Wellbeing Board (22/01/2015) • Meeting with the Local authority

(12/11/2014) • Waltham Forest LMC (6/11/2014 &

7/01/2015)

• Commissioning Cluster Leads meeting (3/12/2014)

• Commissioning Clusters evening event at West Ham Football Ground (10/12/2014)

• NE1 Cluster meeting (15/12/2014) • South 1&2 cluster meeting

(18/12/2014) • Newham GP Practice Council

(28/11/2014) • Newham LMC meeting

(25/11/2014) • Newham Health and Wellbeing

Board (7/01/2015) • Meeting with the Healthwarch

(7/01/2015)

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Timeline following 9th January submission

Provide information to governing board for final sign off of application, COI policy, TOR, Constitution and delegation WF – 28/01/2015 Newham – 28/01/2015 (Board Development Session) Tower Hamlets – 27/01/2015 Start Lay Member recruitment w/c 29/01/2015

Due diligence on finances communicated to GB WF – 25/02/2015 Final sign off Newham – 11/02/2015

Lay member recruitment interviews 15/03/2015 Due diligence on finances communicated to GB Tower Hamlets – 3/03/2015 SOPs for teams and ways of working between the Committee and WEL Collaborative Forum finalised by w/c 30/03/2015

First meeting of the Primary Care Committees w/c 20/04/2015 Lay member inductions w/c 6/04/2015

First meeting of the WEL Collaborative Forum w/c 25/05/2015

January February March April May

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To know more If you would like to discuss any element of this presentation, please contact our team on: Tel: 0781 867 6463 Email: [email protected] www.nelcsu.nhs.uk 141

Terms of Reference – Tower Hamlets CCG Primary Care Commissioning Committee

Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014

that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

2. 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 Tower Hamlets CCG. The delegation is set out in Schedule 1.

3. The CCG has established the 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.

4. It is a committee comprising representatives of the following organisations:

• Tower Hamlets CCG; • NHS England

Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary

carecommissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the Board and the CCG.

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7. 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).

8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those set out below:

• Duty to have regard to impact on services in certain areas (section 13O); • Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a committee of the Tower Hamlets CCG

Governing Body in accordance with Schedule 1A of the “NHS Act”. 10. The members acknowledge that the Committee is subject to any directions made

by NHS England or by the Secretary of State.

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Role of the Committee 11. The Committee has been established in accordance with the above statutory

provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in Tower Hamlets under delegated authority from NHS England.

12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Tower Hamlets CCG, which will sit alongside the delegation and terms of reference.

13. The functions of the Committee are undertaken in the context of a desire to

promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. 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.

15. This includes the following:

• 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);

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

Enhanced Services”);

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

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

• Approving practice mergers; and

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

16. The CCG will also carry out the following activities:

See Appendix A for the scope of co-commissioning activities

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Geographical Coverage 17. The Committee will comprise of decisions relating to primary care in Tower

Hamlets

Membership 18. The Committee shall consist of:

The membership of the Committee will be: Voting members: Lay chair (from CCG), Lay vice chair (from CCG), Board Nurse, Board Secondary Care Consultant, CCG Chief Finance Officer, Independent Clinical Adviser, CCG Accountable Officer Non-voting members: HWBB rep (LA member), Public Health rep, Health watch rep, LMC, 2 x additional CCG GPs, NHS England Representative

19. The Chair of the Committee shall be a CCG Lay Member (which member is TBC)

20. The Vice Chair of the Committee shall be a CCG Lay Member (which member

is TBC)

21. Non-voting members will be Healthwatch, LMC, Public Health and HWBB member (Local Authority rep)

Meetings and Voting 22. The Committee will operate in accordance with the CCG’s Standing Orders. The

Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 7 days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

23. Each 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

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second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible.

Quorum

The Committee will be Quorate with three of the seven voting members in attendance, with at least one Lay member present. Where the GP member has a conflict of interest they will be excluded from the agenda item discussion and decision.

Frequency of meetings 24. The committee shall meet monthly

25. Meetings of the Committee shall:

a) be held in public, subject to the application of 23(b);

b) 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.

26. Members of the Committee have a collective responsibility for the operation of

the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

27. 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 parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest..

28. The Committee may call additional experts to attend meetings on an ad hoc

basis to inform discussions.

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29. Members of the Committee shall respect confidentiality requirements as set out in the CCG Constitution or Standing Orders.

30. The Committee will present its minutes to the London Area Team of NHS

England and the governing body of Tower Hamlets CCG each month for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 27 above.

31. The CCG will also comply with any reporting requirements set out in its

constitution. 32. It is envisaged that these Terms of Reference will be reviewed annually,

reflecting experience of the Committee in fulfilling its functions. NHS England may also issue revised model terms of reference from time to time.

Accountability of the Committee

Budget and resource accountability for the Committee will be reviewed in February 2015 following financial due diligence prior to transfer

For the avoidance of doubt, in the event of any conflict between the terms of this Scheme of Delegation and Terms of Reference and the Standing Orders of Standing Financial Instructions of any of the members, the latter will prevail.

Procurement of Agreed Services

We will adhere to the Conflicts of Interest guidance release 2014

See delegation agreement TBC pending final arrangements

Decisions 33. The Committee will make decisions within the bounds of its remit.

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34. The decisions of the Committee shall be binding on NHS England and Tower Hamlets, CCG.

35. The Committee will produce an executive summary report which will be

presented to NHS England and the governing body of Tower Hamlets CCG each month for information.

[Signature provisions]

[Schedule 1 – Delegation-to be added when final arrangements confirmed]

[Schedule 2 – Delegated functions-to be added when final arrangements confirmed]

[Schedule 3 - List of Members-to be added when confirmed]

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June 2014 NHS Tower Hamlets CCG Constitution 71

Appendix D – Scheme of Reservation and Delegation of Powers

The arrangements made by the group as set out in this scheme of reservation and del egation of decisions shall have effect as if incorporated in the group’s constitution. The Clinical Commissioning Group Membership remains accountable for all of its functions, including those that it has delegated.

1. Decisions / duties reserved by, the CCG Membership

Reference

Decisions / duties

Regulation and Control

Determine the arrangements by which the members of the group approve those decisions that are reserved for the membership.

Consider and approve applications to the NHS England on any matter concerning changes to the group’s constitution, including terms of reference for the group’s governing body, its committees, membership of committees, the overarching scheme of reservation and delegated powers, arrangements for taking urgent decisions, standing orders and prime financial policies.

Approval of the group’s overarching scheme of reservation and delegation.

Approve the arrangements for identifying practice members to represent practices in matters concerning the work of the group; and

Appointing clinical leaders to represent the group’s membership on the group’s governing body, for example through election (if desired).

Approve the appointment of governing body members, the process for recruiting and removing non- elected members to the governing body (subject to any regulatory requirements) and succession planning.

Approve arrangements for identifying the group’s proposed Chief Officer.

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2. Decisions / Duties delegated by the CCG Membership to, and reserved by, the CCG Governing Body

Reference

Decisions / duties

152



Approve detailed financial policies.

Prepare the group’s overarching scheme of reservation and delegation.

Prepare and recommend an operational scheme of delegation that sets out who has responsibility for operational decisions within the group.

Approve the group’s operational scheme of delegation that underpins the group’s “overarching scheme of reservation and delegation” as set out in the constitution.

Exercise or delegate those functions of the CCG which have not been retained as reserved by the group, delegated to a committee or sub-committee of the group or to one of its members or employees.

Approve arrangements for managing exceptional funding requests.

Require and receive the declaration of Governing Body members’ interests which may conflict with those of the CCG and, taking account of any waiver which the Secretary of State for Health may have made in any case, determining the extent to which that member may remain involved with the matter under consideration.

Require and receive the declaration of officers’ interests that may conflict with those of the CCG.

Receive reports from the CCG Executive, committees and Locality Boards including those that the CCG is required by the Secretary of State or other regulation to establish and to action appropriately.

Confirm the recommendations of the CCG Executive, CCG committees and Locality Boards where the committees / Boards do not have executive powers.

Approve arrangements relating to the discharge of the CCG’s responsibilities as a corporate trustee for funds held on trust.

Establish terms of reference and reporting arrangements for the CCG Executive, CCG committees and Lo cality Boards established by the Governing Body.

Set out who can execute a document by signature by signature / use of the seal.

Discipline members of the Governing Body, CCG Executive, Locality Board members or employees who are in

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Reference

Decisions / duties

breach of statutory requirements or SOs.

15. Approve any urgent decisions taken by the chair of the CCG and Chief Officer for ratification.

Strategy and Planning

Agree the vision, values and overall strategic direction of the group.

Approve the group’s operating structure.

Approve the group’s commissioning plan.

Approve the group’s corporate budgets that meet the financial duties as set out in the main body of the constitution.

Approve variations to the approved budget where variation would have a significant impact on the overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims.

Approve plans in respect of the application of available financial resources to support the agreed commissioning plan.

Approve annually (with any necessary appropriate modification) the CCG Operating Plan and budgets.

Approve the opening of bank accounts.

Approve audit committee proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and Chief Finance Officer (for losses and special payments) previously approved by the Governing Body.

Approve Executive Committee’s proposals on individual contracts (other than NHS contracts) amounting to, or likely to amount to over £100,000 over a 3 year period or the period of the contract if longer.

Approve individual compensation payments.

Annual Reports and Accounts

Approval of the group’s annual report and annual accounts.

Receipt and approval of the Annual Report and Accounts for funds held on trust.

Approval of the arrangements for discharging the group’s statutory financial duties.

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Reference

Decisions / duties

Receive the annual management letter received from the external auditor and agreement of CCG

Executive’s proposed action, taking account of the advice, where appropriate, of the audit committee.

6. Receive an annual report from the Internal Auditor and agree action on recommendations where appropriate of the audit committee.

Human Resources

Approve the terms and conditions, remuneration and travelling or other allowances for governing body members, including pensions and gratuities.

Approve disciplinary arrangements for employees, including the Chief Officer (where he / she is an em ployee or member of the Clinical Commissioning Group) and for other persons working on behalf of the group.

Review disciplinary arrangements where the Chief Officer is an employee or member of another Clinical Commissioning Group.

Approval of the arrangements for discharging the group's statutory duties as an employer.

Approve human resources policies for employees and for other persons working on behalf of the group including the arrangements for the appointment, removal and remuneration of staff.

To monitor the development and implementation of an organisational development plan.

7. Approve recommendations of the Remuneration Committee regarding directors and senior employees and t hose recommendations of the Chief Officer for staff not covered by the Remuneration Committee.

Operational and Risk Management

Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006).

Approve the CCG’s policies and procedures for the management of risk.

Approve proposals for action on litigation against or on behalf of the CCG.

Approve the group’s arrangements for business continuity and emergency planning.

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Reference

Decisions / duties

Information Governance

Approve the group’s arrangements for handling complaints.

Approval of arrangements for ensuring appropriate safekeeping and confidentiality of records and for the storage, management and transfer of information and data.

Tendering & Contracting

Approval of the group’s contracts for any commissioning support.

Approval of the group’s contracts for corporate support (for example finance provision).

Partnership Working

Approve decisions that individual members or employees of the group participating in joint arrangements on behalf of the group can make. Such delegated decisions must be disclosed in this scheme of reservation and delegation.

Approve decisions delegated to joint committees established under section 75 of the 2006 Act.

Commissioning and Contracting for Clinical Services

Approval of the arrangements for discharging the group’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation.

Approve arrangements for co-ordinating the commissioning of services with other groups and or with the local authority(ies), where appropriate.

Adopt the Local Commissioning Plans.

Approve the Locality Commissioning Plan.

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Reference

Decisions / duties

Communications

1. Approving arrangements for handling Freedom of Information requests.

Equality

1. Ensure that the CCG meets the public sector equality duty.

Other

1. Obtain appropriate advice from persons who, taken together, have a broad range of professional expertise in healthcare and public health.

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3. Decisions / Duties delegated by the Governing Body to, and reserved by, the CCG Executive Team

Reference

Decisions / duties


Prepare detailed financial policies that underpin the CCG’s prime financial policies.

Require and receive the declaration of any CCG Executive member’s interests which may conflict with those of the CCG and taking account of any waiver which the Secretary of State may have made in any case, and after consultation with the CCG Chief Officer, determining the extent to which that member may participate in the consideration of a matter in which he / she has an interest.

Verify instances of failure to comply with Standing Orders brought to the Chief Officer’s attention. Such failures to be reported to the next formal meeting of the CCG.

Continuous appraisal of the affairs of the CCG by means of the provision to the Governing Body as the Governing Body may require from directors, committees, and officers of the CCG as set out in management policy statements. All monitoring returns required by the Department of Health and the Charity Commission shall be reported, at least in summary, to the Governing Body.

Receive and approve a schedule of NHS service agreements signed in accordance with arrangements agreed with the Chief Officer.

To provide an informal opportunity to arbitrate in disputes between localities.

Strategy and Planning

Develop county-wide CCG commissioning plans and standards.

To prepare and review locality based commissioning budgets and plans prior to approval by the CCG (approval of locality boards also required).

To oversee service and pathway redesign where this takes place across the County or a number of Localities.

To provide clinical and organisational scrutiny of all other commissioning decisions based on data, analysis and evidence.

To lead the development of a County wide vision and strategy for the commissioning of all hospital based care, community and mental health services.

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Reference

Decisions / duties

To encourage plurality of choice whilst ensuring that clinical governance and quality standards are met.

To tackle health inequalities across Tower Hamlets assessing the extent to which inequalities are being reduced and quality and outcomes are improving.

To ensure alignment and coordination across practices and locality groupings and t o ensure multi professional engagement.

Advise on approval of individual compensation payments.

Advise on approval of individual contracts (other than NHS contracts) amounting to, or likely to amount to over £100,000 over a 3 year period or the period of the contract if longer.

To advise on the introduction or discontinuance of any significant activity or operation. An activity or operation shall be regarded as significant if it has a gross annual income or expenditure (that is before any set off) in excess of

£100,000.

To consider business cases for investment in County-wide schemes.

Annual Report and Accounts

1. Prepare, consider and endorse the CCG’s draft Annual Report (including the annual accounts) for approval by the Governing Body.

Quality and Safety

To ensure the quality of services commissioned from providers is of a high quality and continuously improving..

Assist and support the NHS England in improving the quality of primary medical services.

To co-ordinate the delivery of effective safeguarding arrangements.

Operational and Risk Management

Develop the CCG’s policies and procedures for the management of risk.

Consider and make recommendations to the Governing Body on action on litigation against or on behalf of the CCG.

159


Reference

Decisions / duties

To establish a corporate performance framework.

To act with a view to promoting integration of health services with other health services and health services with health–related and social care services where the group considers that this would Improve the quality of services or reduce inequalities.

To support the management of overall CCG clinical and financial performance against plans.

To manage Tower Hamlets-wide strategic risks.

To manage the continuing care budget and other County-wide risk budgets on behalf of the Localities.

Respond to decisions on Specialised Commissioning made by the NCB.

Communications

Determining arrangements for handling Freedom of Information requests.

To maintain effective relationships with County-wide partners, providers and key stakeholders across Tower Hamlets and NHS England

160


4. Decisions / Duties delegated by the Governing Body to, and reserved by, the Locality Boards

Reference

Decisions / duties

To lead and set the Locality vision and strategy.

To develop Locality commissioning plans

To drive improvements in quality and outcomes and reduce inequalities.

To drive effective safeguarding arrangements.

To maintain effective relationships with partners, providers and key stakeholders in the Locality.

To manage Locality resources within budget and financial targets.

To manage Locality clinical and financial performance against plans.

To oversee service and pathway redesign where this takes place within the Locality (or with a neighbouring Locality).

To agree business cases within Locality budgets.

To manage risk within the Locality.

161


5. Decisions / Duties delegated by the Governing Body to the Audit Committee

Reference

Decisions / duties

Integrated Governance, Risk Management and Internal Control

The committee shall approve the group’s risk management arrangements. In doing so it will review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities (both clinical and non- clinical), that supports the achievement of the CCG’s objectives.

Internal Audit

The committee shall ensure that there is an effective internal audit function that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the audit committee and Chief Officer and advise the CCG accordingly. The committee will appoint the internal auditors and approve the internal audit plan.

External Audit

The committee shall review the work and findings of the external auditors, consider the implications and management’s responses to their work and advise the CCG.

Counter Fraud & Security Management

The committee shall approve the group’s counter fraud and security management arrangements.

Internal Control and Financial Reporting

The audit committee shall approve arrangements for discharging the group’s statutory financial duties.

The committee shall approve a comprehensive system of internal control, including budgetary control, that underpins the effective efficient and economic operation of the group.

The audit committee shall monitor the integrity of the financial statements of the CCG and any formal announcements relating to the CCG’s financial performance.

The audit committee shall review the annual report and financial statements before submission to the Governing Body.

162


Reference

Decisions / duties

Other Assurance Functions

9. The audit committee shall review the findings of other significant assurance functions, both internal and external and consider the implications to the governance of the CCG. These will include, but will not be limited to, any reviews by Department of Health arm’s length bodies or Regulators / Inspectors (e.g. Care Quality Commission and NHS Litigation Authority), and professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges and accreditation bodies).

In addition, the committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the audit committee’s own scope of work.

Advise on individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Officer and Chief Finance Officer (for losses and special payments) previously approved by the Governing Body.

Monitor compliance with Standing Orders and Prime Financial Policies.

163


6. Decisions / Duties delegated by the Governing Body to the Remuneration Committee

Reference

Decisions / duties

Make recommendations to the Governing Body on the terms and conditions of employment for the Chief Officer, other executive directors and other senior employees including:

all aspects of salary (including any performance-related elements/bonuses);

provisions for other benefits, including pensions and cars;

arrangements for termination of employment and other contractual terms.

Review disciplinary arrangements where the Chief Officer is an employee or member of another CCG.

Make recommendations to the Governing Body on an y proposed remuneration for the Chief Officer, other executive directors and other senior employees for specific work in addition to their corporate CCG role, so as to ensure that the individual is fairly rewarded for their individual contribution to the CCG while having proper regard to the CCG's circumstances and performance, and to the requirements of fair and open tendering or recruitment policies;

Consider any severance payments to the Chief Officer and other senior staff taking account of such national guidance as is appropriate advise on and oversee appropriate contractual arrangements for such staff;

164


7. Decisions / Duties delegated by the Governing Body to the Finance, Performance & Quality Committee

Reference

Decisions / duties


Approve arrangements for managing exceptional funding requests

Quality and Safety

Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to secure continuous improvement in quality and patient outcomes

Approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services.

165


8. Decisions / Duties delegated by the Governing Body to the Transformation & Innovation Committee

Reference

Decisions / duties

Identify areas where service transformation projects can lead to health, quality and fiscal improvements for the population of Tower Hamlets

Review all new and revised clinical pathways being proposed as part of service transformation

Support and review the development of business cases for service transformation work

Make recommendations to the Governing Body on areas for investment in service transformation, innovation, research and development

Review and make recommendations to the Governing Body on proposals for innovation projects

Ensure a transparent process for the allocation of innovation grants

6Ensure that the CCG develops systems to promote research and development, locally and i n partnership with other organisations, such as the Academic Health Sciences Network and the Clinical Effectiveness Group

Focus on the principles of integrated care in developments to new and existing services to ensure there is more coordination and integration in care provision across the borough

166


9. Decisions / Duties delegated by the Governing Body to the Individual Funding Request Panel

Reference

Decisions / duties

1. The panel will make decisions on funding areas of healthcare which fall outside of their statutory responsibility.

167


10. Decisions delegated by the Governing Body

Delegated to

Decisions / Duties

Chief Officer

Accountable through NHS Chief Officer Memorandum to Parliament for stewardship of CCG resources. Chief Officer

&

Chief Finance Officer

Ensure the accounts of the CCG are prepared under principles and in a format directed by the Secretary of State. Accounts must disclose a true and fair view of the CCG’s income and expenditure and its state of affairs.

Sign the accounts on behalf of the Governing Body. Chief Officer

Sign a statement in the accounts outlining responsibilities as the Chief Officer.

Sign a statement in the accounts outlining responsibilities in respect of Internal Control.

Ensure effective management systems that safeguard public funds and assist CCG chair to implement requirements of integrated governance including ensuring managers:

have a clear view of their objectives and the means to assess achievements in relation to those objectives;

be assigned well defined responsibilities for making best use of resources

have the information, training and access to the expert advice they need to exercise their responsibilities effectively.

Chair

Implement requirements of corporate governance. Chief Officer

Achieve value for money from the resources available to the CCG and avoid waste and extravagance in the organisation's activities.

Follow through the implementation of any recommendations affecting good practice as set out in reports from such bodies as the Audit Commission and the National Audit Office (NAO).

Use to best effect the funds available for commissioning healthcare, developing services and promoting health to meet the needs of the local population.

168


Delegated to

Decisions / Duties


To provide the Governing Body with expert advice on finance ensuring, through robust systems and processes, the regularity and propriety of expenditure is fully discharged.

To make appropriate arrangements to support, monitor on the group’s finances.

To oversee robust audit and governance arrangements leading to propriety in the use of the group’s resources.

To advise the governing body on the effective, efficient and economic use of the group’s allocation to remain within that allocation and deliver required financial targets and duties.

To produce the financial statements for audit and publication in accordance with the statutory requirements to demonstrate effective stewardship of public money and accountability to NHS England.

To make appropriate arrangements to support, monitor on the group’s finances.

To oversee robust audit and governance arrangements leading to propriety in the use of the group’s resources.

To advise the governing body on the effective, efficient and economic use of the group’s allocation to remain within that allocation and deliver required financial targets and duties.

To produce the financial statements for audit and publication in accordance with the statutory requirements to demonstrate effective stewardship of public money and accountability to NHS England.

Chief Officer

Whilst effective and sound financial management and information is the operational responsibility of the Chief Finance Officer it is a primary duty of the Chief Officer to ensure that the Chief Finance Officer properly discharges this function. The Chief Officer will also ensure that the assets of the PCT are properly safeguarded.

Ensuring that expenditure by the CCG complies with Parliamentary requirements.

The Codes of Conduct and Accountability incorporated in the Corporate Governance Framework issued to NHS Governing Bodies by the Secretary of State are fundamental in exercising their responsibilities for regularity and probity. As a Governing Body member they have explicitly subscribed to the Codes and should promote observance by all staff.

169


Delegated to

Decisions / Duties

Chief Officer

&


Chief Officer, supported by Chief Finance Officer, to ensure appropriate advice is given to the Governing Body on all matters of probity, regularity, prudent and economical administration, efficiency and effectiveness.

Chief Officer

If the Chief Officer considers that the chair of the Governing Body is doing something that might infringe probity or regularity, he / she should set this out in writing to the chair and the Governing Body. If the matter is unresolved, he / she should ask the audit committee to inquire and if necessary the SHA and Department of Health.

If the Governing Body is contemplating a course of action that raises an issue not of formal propriety or regularity but affects the Chief Officer’s responsibility for value for money, the Chief Officer should draw the relevant factors to the attention of the Governing Body. If the outcome is that the Chief Officer is overruled it is normally sufficient to ensure that the Chief Officer’s advice and the overruling of it are clearly apparent from the papers. Exceptionally, the Chief Officer should inform the NHS England and the DH. In such cases, and in those described in reference 24, the Chief Officer should as a member of the Governing Body vote against the course of action rather than merely abstain from voting.

To have regard of the need to promote education and training for persons employed, or considering employment in an activity involving or connected with the provision of services as part of the health service in England.

170


11. Scheme of Delegation derived from the codes of conduct and accountability

Delegated to

Decisions / Duties

Governing Body

Approve procedure for declaration of hospitality and sponsorship.

Ensure proper and widely publicised procedures for voicing complaints, concerns about maladministration, breaches of Code of Conduct, and other ethical concerns.

All Governing Body Members

Subscribe to Code of Conduct.

Governing Body

Governing Body members share corporate responsibility for all decisions of the Governing Body.

Chair and non- officer Members

Chair and lay members are responsible for monitoring the executive management of the organisation and are responsible to the Secretary of State for the discharge of those responsibilities.

171


12. Scheme of Delegation from model standing orders

Delegated to

Decisions / Duties

Chair

Final authority in interpretation of Standing Orders.

Governing Body

Appointment of vice-chair. Chair

Calling meetings.

Chair all Governing Body meetings and associated responsibilities.

Give final ruling in questions of order, relevancy and regularity of meetings.

Having a second or casting vote.

Governing Body

Suspension of Standing Orders.

Audit Committee

Audit committee to review every decision to suspend Standing Orders (power to suspend Standing Orders is reserved to the Governing Body).

172


Delegated to

Decisions / Duties

Governing Body

Variation or amendment to Standing Orders.

The Governing Body shall approve the appointments to each of the committees which it has formally constituted.

Establish a Remuneration & Terms of Service Committee.

Remuneration Committee

Advise the Governing Body on and make recommendations on the remuneration and terms of service of the Chief Officer, other officer members and senior employees to ensure they are fairly rewarded having proper regard to the CCG’s circumstances and any national agreements.

Monitor and evaluate the performance of individual senior employees.

Advise on and oversee appropriate contractual arrangements for such staff, including proper calculation and scrutiny of termination payments.

Report in writing to the Governing Body its advice and its bases about remuneration and terms of service

Chair

&

Chief Officer

The powers which the Governing Body has retained to itself within these Standing Orders may in emergency be exercised by the chair and Chief Officer after having consulted at least two lay members.

173


Delegated to

Decisions / Duties

Governing Body

Formal delegation of powers to other committees, sub-committees or joint committees and approval of their constitution and terms of reference. (The Chief Officer may approve Constitution and terms of reference of sub- committees.)

Chief Officer

The Chief Officer shall prepare a Scheme of Delegation identifying his / her proposals, which shall be considered and approved by the Governing Body, subject to any amendment agreed during the discussion.

All

Disclosure of non-compliance with Standing Orders to the Chief Officer as soon as possible.

All governing body members

Declare relevant and material interests.

Chief officer

Maintain Register(s) of Interests.

Chair of a Meeting

Making a declaration on a declared interest.

All Staff

Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff” and the Code of Conduct for NHS Managers 2002.

All

Disclose of relationship between self and candidate for staff appointment. (Chief Officer to report the disclosure to the Governing Body.

174


Delegated to

Decisions / Duties

Chief Officer

Keep seal in safe place and maintain a register of sealing.

Approve and sign all documents which will be necessary in legal proceedings.

175


13. Scheme of Delegation from Prime Financial Policies Delegated to

Decisions / Duties


Approval of all financial procedures.


Advice on interpretation or application of Prime Financial Policies.

All Members of the Governing Body and Employees

Have a duty to disclose any non-compliance with the Prime Financial Policies to the Chief Finance Officer as soon as possible.

Chief Officer

Ensure that any contractor or employee of a contractor who is empowered by the CCG to commit the CCG to expenditure or who is authorised to obtain income are made aware of these instructions and their requirement to comply.

Governing Body

Will establish an audit committee with terms of reference agreed by the Governing Body.

Audit Committee

Will ensure effective internal control arrangements are in place, and provide a form of independent check upon the executive arm of the Governing body.

Chair of the Audit Committee

Raise the matter at the Governing Body meeting where chair of audit committee considers there is evidence of ultra vires

176


Delegated to

Decisions / Duties

transactions or improper acts.

CHIEF OFFICER

Has overall responsibility for the group’s system of internal control.

177


Delegated to

Decisions / Duties


Will ensure that:

Financial policies are considered for review and update annually;

Ensure an adequate internal audit service, for which he/she is accountable, is provided (and involve the audit committee in the selection process when/if an internal audit service provider is changed.)

Ensure the annual audit report is prepared for consideration by the audit committee.

A system is in place for proper checking and reporting of all breaches of financial policies;

A proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.

Decide at what stage to involve police in cases of misappropriation and other irregularities not involving fraud or corruption

Head of Internal Audit

Review, appraise and report in accordance with NHS Internal Audit Standards and best practice.

Audit Committee

Ensure cost-effective external audit.

178


Delegated to

Decisions / Duties

Chief Officer

&


Monitor and ensure compliance with Secretary of State Directions on fraud, corruption and bribery including the appointment of the Local Counter Fraud Specialist.


Ensure that the CCG’s expenditure does not exceed the aggregate of allotments from the NHS England and any sums it has received and is legally allowed to spend.

Chief Officer

Compile and submit to the Governing Body a commissioning plan which takes into account financial targets and forecast limits of available resources. The plan will contain:

a statement of the significant assumptions on which the plan is based;

details of major changes in workload, delivery of services or resources required to achieve the plan.


Approve consultation arrangements for the group’s commissioning plan.

Chief Officer

Has overall responsibility for ensuring that the group complies with certain of its statutory obligations including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which

179


Delegated to

Decisions / Duties

provides good value for money.


Submit budgets to the Governing Body for approval.

Will ensure draw down for approved expenditure is timely and follows best practice in cash management.

Will ensure that an adequate system for monitoring financial performance is in place.

Ensure adequate training is delivered on an ongoing basis to budget holders.

Ensure that Governing Body members are aware of DH guidance on financial issues.

180


Delegated to

Decisions / Duties

Chief Officer

Delegate the management of budget to budget holders.

Chief Officer

&

Budget Holders

Must not exceed the budgetary total or virement limits set by the Governing Body.

Chief Officer

Shall take immediate control of any budgeted funds not required for their designated purpose.

Chief Officer

&


Shall take responsibility for authorising the use any non recurrent budgets to finance recurring expenditure.


Shall monitor financial performance against budget and plan, periodically review them and report to the Governing Body.

181


Delegated to

Decisions / Duties

Budget Holders

Shall provide to the Chief Finance Officer sufficient information to compile budgets.

Shall obtain the prior consent of the Governing Body for any likely overspend or reduction of income which cannot be met by virement.

Shall ensure that the amount provided in budget is not used in whole or in part for any purpose other than that specifically authorised, subject to the rules of virement.

Shall not appoint employees without the approval of the Chief Officer other than those provided for within the available resources and manpower establishment as approved by the Governing Body.

Chief Officer

Identify and implement cost improvements and income generation activities in line with the plan.

Submit monitoring returns.


Preparation of annual accounts and reports.

Responsible for accuracy and security of computerised financial data.

182


Delegated to

Decisions / Duties


Satisfy him / herself that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

CSU Director with responsibility for governance

Shall publish and maintain a Freedom of Information Scheme.

Relevant Officers

Send proposals for general computer systems to CFO.


Ensure that contracts with other bodies for the provision of computer services for financial applications clearly define responsibility for all parties for security, privacy, accuracy, completeness and timeliness of data during processing, transmission and storage, and allow for audit review.

Seek periodic assurances from the provider that adequate controls are in operation.

Where computer systems have in impact on corporate financial systems satisfy himself that:

systems acquisition, development and maintenance are in line with corporate policies;

data assembled for processing by financial systems is adequate, accurate, complete and timely, and that a management rail exists;

183


Delegated to

Decisions / Duties

CFO and staff have access to such data;

Such computer audit reviews are being carried out as are considered necessary.

Managing banking arrangements, including provision of banking services, operation of accounts, preparation of instructions and list of cheque signatories.

(Governing Body approves arrangements.)

Review the banking arrangements of the CCG at regular intervals to ensure they reflect best practice and represent best value for money.

Ensure competitive tenders are sought at least every 5 years.

Income systems, including system design, prompt banking, review and approval of fees and charges, debt recovery arrangements, design and control of receipts, provision of adequate facilities and systems for employees whose duties include collecting or holding cash.

All employees

Duty to inform CFO of money due from transactions which they initiate / deal with.

184


Delegated to

Decisions / Duties

Chief Officer

Tendering and contracting procedure.

Waive formal tendering procedures.


Report waivers of tendering procedures to the audit committee.

Where a supplier is chosen that is not on the approved list the reason shall be recorded in writing to the Chief Officer.

Chief Officer

Responsible for the receipt, endorsement and safe custody of tenders received.

Shall maintain a register to show each set of competitive tender invitations dispatched.

Chief Officer

&


Where only one tender is received will assess for value for money and fair price.

185


Delegated to

Decisions / Duties

Chief Officer

Responsible for treatment of “late tenders”.

No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the CCG and which is not in accordance with these Policies except with the authorisation of the Chief Officer.

Will appoint a manager to monitor the National Framework Agreements approved by the Government Procurement Service

chief Finance Officer

Shall ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

Chief Officer

The Chief Officer or his nominated officer should evaluate the quotation and select the quote which gives the best value for money.

Chief Officer

Or


No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the CCG and which is not in accordance with these Instructions except with the authorisation of the Chief Officer.

186


Delegated to

Decisions / Duties

Chief Officer

The Chief Officer shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

The Governing Body

All PFI proposals must be agreed by the Governing Body.

Chief Officer

The Chief Officer shall nominate an officer who shall oversee and manage each contract on behalf of the CCG.

The Chief Officer shall nominate officers with delegated authority to enter into contracts of employment, regarding staff, agency staff or temporary staff service contracts.

The Chief Officer shall nominate officers to commission service agreements with providers of healthcare in line with a commissioning plan approved by the Governing Body.

The Chief Officer shall be responsible for ensuring that best value for money can be demonstrated

The Chief Officer shall nominate an officer to oversee and manage the contract on behalf of the CCG.

As the Chief Officer, ensure regular reports are provided to the Governing Body detailing actual and forecast

187


Delegated to

Decisions / Duties

expenditure for each SLA.


Will maintain a system of control to ensure effective accounting of expenditure against SLAs.

Must account for Out of Area Treatments/Non Contract Activity in accordance with national guidelines.

Governing Body

Approve proposals presented by the Chief Officer for determination of commencing pay rates and conditions of service for those employees and officers not covered by the Remuneration Committee.

Chief Officer

Approval of variation to funded establishment of any department.

Approval of appointment of staff, including agency staff, appointments and re-grading within approved budget and funded establishment.


Payroll:

specifying timetables for submission of properly authorised time records and other notifications;

final determination of pay and allowances;

188


Delegated to

Decisions / Duties

making payments on agreed dates;

agreeing method of payment;

issuing instructions.

Nominated Managers

Submit time records in line with timetable;

Complete time records and other notifications in required form;

Submitting termination forms in prescribed form and on time.


Ensure that the chosen method for payroll processing is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements Are made for the collection of payroll deductions and payment of these to appropriate bodies.

CSU Director with responsibility for Human Resources

Ensure that all employees are issued with a Contract of Employment in a form approved by the Governing Body and which complies with employment legislation;

Deal with variations to, or termination of, contracts of employment.

189


Delegated to

Decisions / Duties

Governing Body

The Governing Body will approve the level of non-pay expenditure on an annual basis.

Chief Officer

Determine, and set out, level of delegation of non-pay expenditure to budget managers, including a list of managers authorised to place requisitions, the maximum level of each requisition and the system for authorisation above that level.

Set out procedures on the seeking of professional advice regarding the supply of goods and services.

Requisitioner*

In choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the CCG. In so doing, the advice of the CCG's adviser on supply shall be sought.


Advise the Governing Body regarding the setting of thresholds above which quotations (competitive or otherwise) or

formal tenders must be obtained; and, once approved, the thresholds should be incorporated in Standing Orders and regularly reviewed;

Prepare procedural instructions [where not already provided in the Scheme of Delegation or procedure notes for budget holders] on the obtaining of goods, works and services incorporating the thresholds;

Be responsible for the prompt payment of all properly authorised accounts and claims;

Be responsible for designing and maintaining a system of verification, recording and payment of all amounts

190


Delegated to

Decisions / Duties

payable;

Be responsible for ensuring that payment for goods and services is only made once the goods and services are received.

Budget Holder

Ensure that all items due under a prepayment contract are received (and immediately inform CFO if problems are encountered).

Chief Officer

Authorise who may use and be issued with official orders.

Managers and Officers

Ensure that they comply fully with the guidance and limits specified by the Chief Finance Officer.

Chief Officer

&


Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within CONCODE and ESTATECODE. The technical audit of these contracts shall be the responsibility of the relevant director.


Lay down procedures for payments to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act.

191


Delegated to

Decisions / Duties

Chief Officer

Capital investment programme:

ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the effect that each has on plans;

responsible for the management of capital schemes and for ensuring that they are delivered on time and within cost;

ensure that capital investment is not undertaken without availability of resources to finance all revenue consequences, including capital charges;

be responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

Chief Officer

Maintenance of asset registers (on advice from CFO).


Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

Calculate and pay capital charges in accordance with Department of Health requirements.

192


Delegated to

Decisions / Duties

Chief Officer

Overall responsibility for fixed assets.


Approval of fixed asset control procedures.

Governing Body

Executive Team

and all Senior Staff

Responsibility for security of CCG assets including notifying discrepancies to CFO, and reporting losses in accordance with CCG procedure.

All Members of the Governing Body and Employees

Responsible for security of the CCG’s property, avoiding loss, exercising economy and efficiency in using resources and conforming to Standing Orders, Prime Financial Policies and financial procedures.

Chief Officer

Identify persons authorised to requisition and accept goods from NHS Supply Chain stores.


Prepare detailed procedures for disposal of assets including condemnations and ensure that these are notified to managers.

193


Delegated to

Decisions / Duties


Prepare procedures for recording and accounting for losses and special payments.

All Staff

Discovery or suspicion of loss of any kind must be reported immediately to either head of department or nominated officer. The head of department / nominated officer should then inform the Chief Officer and CFO.


Where a criminal offence is suspected the CFO must inform the police if theft or arson is involved. In cases of fraud and corruption the CFO must inform the relevant Local Counter Fraud Specialist (LCFS) and NHS Counter Fraud Service (NHS CFS) Operational Fraud Team in line with SofS directions.

Notify CFSMS, LCFS and external audit of all frauds.

Notify Governing Body and external auditor of losses caused theft, arson, neglect of duty or gross carelessness (unless trivial).

Governing Body

Approve write off of losses (within limits delegated by DH).


Consider whether any insurance claim can be made.

Maintain a losses and special payments register.

194


Delegated to

Decisions / Duties

Shall ensure that each trust fund which the CCG is responsible for managing is managed appropriately. Ensure all staff are made aware of the CCG policy on the acceptance of gifts and other benefits in kind by staff.

Chief Officer

Ensure lists of all contractors are maintained up to date and systems are in place to deal with applications, resignations, inspection of premises etc. within contractors’ terms of service.


Ensure only contractors included on the CCG lists receive payments; maintain a system of control to ensure prompt and accurate payments and validation of same.

Chief Officer

Retention of document procedures in accordance with Department of Health guidance.

Chief Officer

Risk management programme.

Governing Body

Approve and monitor risk management programme.

Governing Body

Decide whether the CCG will use the risk pooling schemes administered by the NHS Litigation Authority or self- insure for some or all of the risks (where discretion is allowed). Decisions to self-insure should be reviewed annually.

195


Delegated to

Decisions / Duties


Where the Governing Body decides to use the risk pooling schemes administered by the NHS Litigation Authority the Chief Finance Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Finance Officer shall ensure that documented procedures cover these arrangements.

Where the Governing Body decides not to use the risk pooling schemes administered by the NHS Litigation Authority for any one or other of the risks covered by the schemes, the Chief Finance Officer shall ensure that the Governing Body is informed of the nature and extent of the risks that are self-insured as a result of this decision. The Chief Finance Officer will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

196


14 Decisions / Duties delegated by the Governing Body to the Primary Care Committee

Reference

Decisions

/ duties

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) Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”) Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF) Decision making on whether to establish new GP practices in an area Approving practice mergers Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes) The Committee’s detailed Terms of Reference are on the CCG website.

197


198

Next steps towards primary care co-commissioning: Annex E

Draft delegation by NHS England

November 2014

199


2

Draft delegation by NHS England to Tower Hamlets CCG

Introduction

1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting Clinical Commissioning Groups (CCGs) to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would

like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

2. 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 Schedule 1 to these Terms of Reference to Tower Hamlets CCG

3. [The recommendation is that CCGs exercising delegated authority establish

a committee to exercise and oversee the exercise of delegated

commissioning functions. Please see Annex F where template terms of

reference are set out for consideration].

4. The primary purpose of the delegation is to empower Tower Hamlets CCG to commission primary medical services for the people of Tower Hamlets

Statutory Framework

5. Under section 13Z of the NHS Act, NHS England may arrange for any function exercisable by it under the NHS Act to be exercised by a CCG. Arrangements may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG concerned.

6. 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:

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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).

7. The CCG will also need to specifically, in respect of the delegated functions

from NHS England, exercise those set out below: Duty to have regard to impact on services in certain areas (section

13O); Duty as respects variation in provision of health services (section 13P).

8. The CCG remains subject to any directions made by NHS England or by the Secretary of State.

Role of the CCG

9. The CCG will exercise the primary care commissioning functions according to the delegation by NHS England and as set out Schedule 1 to this document.

10. The delegation has been made in the context of a desire to promote

increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

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11. The role of the CCG shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act, except those relating to individual GP performance management, which have been reserved to NHS England.

This includes the following activities:

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);

Newly designed enhanced services (“Local Enhanced Services” and

“Directed Enhanced Services”);

Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

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

Approving practice mergers; and

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

schemes); 12. The CCG will also carry out the following activities in relation to its delegated

primary care commissioning functions: See Appendix A for scope of Primary Care Activities to be carried out

by Tower Hamlets CCG

Geographical Coverage

13. The delegation relates to the geographical area of the Tower Hamlets

Exercise of delegated authority

14. NHS England and the CCG have entered into an agreement that sets out the detailed arrangements for how the CCG will exercise its delegated authority. The CCG will exercise its delegated authority in accordance with the terms of that agreement.

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

authority, provided that they are in accordance with the statutory framework (including Schedule 1A of the NHS Act) and with the CCG’s Constitution.

16. Tower Hamlets will form a Primary Care Commissioning Committee.

The Committee will have a Lay and Executive majority.

Procurement of Agreed Services

The CCG will make procurement decisions as relevant to the exercise of its delegated authority and in accordance with the detailed arrangements regarding procurement set out in the delegation agreement.

Reporting and audit

17. The CCG will provide a report to NHS England on a monthly basis covering the following: Information on contractual actions taken in the period relating to the issuing of breach/ remedial notices and/ or removing a contract. The development and design of LES, DES and LIS as an alternative to QOF

New practices opened or planned to be opened in the area

Mergers being approved or being decided upon in the area

Decisions made on discretionary payments made in the period

Updates on development work carried out with practices

Updates of work carried out on strategic priorities for the borough

Finance and budget updates as appropriate.

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18. Once the committee is established, the CCG will present the committee minutes to the London Area Team of NHS England and the governing body of NHS Tower Hamlets CCGs.

19. The CCG must also comply with any reporting requirements set out in its

Constitution.

20. Where relevant, NHS England may exercise its powers under sections 14Z17, 14Z18, 14Z19 and 14Z20 of the NHS Act to require information from the CCG.

21. It is envisaged that this delegation will be reviewed annually, reflecting

experience of the CCG in fulfilling its functions.

Financial Accountability

22. The CCG must comply with its statutory financial duties, including those under sections 223H and 223I of the NHS Act.

Decisions

23. The CCG will make decisions within the bounds of its remit.

24. The decisions of the CCG shall be binding on NHS England and Tower

Hamlets CCG.

Termination

25. This delegation may be revoked by NHS England and the circumstances when this may be done are set out in the delegation agreement.

26. The parties may, by agreement, withdraw from delegated commissioning arrangements but the party seeking to terminate must give six months’

notice to partners, with new arrangements starting from the beginning of the next new financial year.

Name: Jane Milligan

Date: 8th January 2015

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Signature:

Schedule 1 – Delegated functions

Appendix A – Scope of Co-commissioning

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List of changes to the NHS Tower Hamlets CCG Constitution 3rd request for variation

Introduction

This document outlines the proposed version 4 of the NHS Tower Hamlets CCG Constitution.

These changes have been / will be discussed at the following groups:

1. Governing Body - January 27 2015 2. Exec Committee – January 20 2015

Changes

The following table provides the following details of the 15 changes to the Constitution:

• Section of change • Location of change • Change • Rationale for change

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# Section Location Change Rationale for change

1 Organisational Structure Pg 14 Addition of the Primary Care Commissioning

Committee as a Committee of the Governing Body and the addition of WEL Collaborative Forum.

As per guidance: Next Steps Towards Primary Care Co-commissioning – NHSE Nov 2014

2 Committees of the Group

Pg 31

6.4.2.5

Addition of the Primary Care Commissioning Committee to the list of the Group’s committees.


3

Joint Arrangements Pg 31 Joint commissioning arrangements with other Clinical Commissioning Groups

Joint commissioning arrangements with NHS England for the exercise of CCG functions

Model wording stipulated by NHSE outlining legislation and local governance for joint working between CCGs, and CCGs and NHSE.

4

Joint Arrangements Pg 35 Inclusion of the WEL Collaborative Forum (Non decision making group to make recommendations on primary care to the WEL CCGs Primary Care Commissioning Committee)

WEL collaborative primary care strategic work.

5 Composition of the Governing Body

Pg 37 The governing body will not have less than 23 members – Deleted

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6.6.2.4 one Allied Health Professional * post currently unfilled – CCG will review post in July 2015

AHP post will be reviewed in 2015 by CCG.

6 Committees of the Governing Body

Pg 38 Addition of the Primary Care Commissioning Committee to the list of the Group’s committees and overview of committee’s functions


7 Conflicts of Interest Pg 45 Bidders, contractors, potential contractors

and service providers are referred to the policy Standards of Business Conduct and Managing Conflicts of Interests

Requirement for declarations of interest as per Managing Conflicts of Interest: Statutory Guidance for CCGs Dec 2014

8 Conflicts of Interest Pg 46 Addition of the Register of Decisions and the

details to be included. Requirement for declarations of interest as per Managing Conflicts of Interest: Statutory Guidance for CCGs Dec 2014

9 Appendix A: Definitions of key descriptions used in this constitution

Pg 56 Update on individuals and organisations covered by Register of Interests requirements.

Requirement for declarations of interest as per Managing Conflicts of Interest: Statutory Guidance for CCGs Dec 2014

10 Governing Body Quorum

Pg 66 Update on alternative Governing Body

Quorum to read: To distinguish the Quorum used by the Governing Body for Primary Care Procurements and those decisions that sit with the Primary Care Commissioning

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3.6.2. When the Governing Body is discussing commissioning that impacts on primary care (excluding commissioning carried out by the Primary Care Commissioning Committee)

Instead of:

3.6.2. When the Governing Body is discussing Primary Care Commissioning

Committee (as per ToR).

11

Scheme of delegation Pg 116 Addition of the Primary Care Commissioning Committee to the Scheme of delegation:

Decisions / Duties delegated by the Governing Body to the Primary Care Committee. Decisions / duties:

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)

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

As per guidance: Next Steps Towards Primary Care Co-commissioning – NHSE Nov 2014 (Annex E)

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Services”)

Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF)

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

Approving practice mergers

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

12

Terms of Reference Pg 200 Inclusion of the Primary Care Commissioning Committee, Terms of Reference.

Outlines governance arrangements for decision making relating to:

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)

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

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Enhanced Services”)

Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF)

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

Approving practice mergers

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

As per Managing Conflicts of Interest: Statutory Guidance for CCGs Dec 2014

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Standards of Business Conduct and Managing Conflicts of Interests

Number: THCCGCG4 Version: 2

Executive Summary

• This document ensures that the actions of TH CCG will be taken, and be seen to be taken, without any possibility of the influence of external or private interest.

• If any such individual has an interest, or becomes aware of an interest which could lead to a conflict of interest in the event of the CCG considering an action or decision in relation to that interest, it must be considered as a potential conflict.

• If in doubt the individual concerned should assume that a potential conflict of interest exists and seek advice from the CCG Governance lead.

Date of ratification To Be Ratified – Governing Body 27.1.15 Document Author(s)

Dr. David Pearce, Susan Aylen-Peacock, Sue Assar, Paul Balson, Justin Phillips

Who has been consulted? Executive Team – July 2013, Audit Committee – 2015, NHSE 2015

Was an Equality Analysis required?

No

With what standards does this document demonstrate compliance?

• NHS Confederation Guidance document • Code of Conduct for NHS Managers 2002 • NHS Code of Conduct and Code of Accountability, 2004 • The Healthy NHS Governing body: Principles for Good

Governance • General Medical Council: Good Medical Practice 2006 • NHS Commissioning Board: Code of Conduct: Managing

conflicts of interest where GP practices are potential providers of CCG-commissioned services, 2012

• Health and Social Care Act 2012 • NHS England - Managing Conflicts of Interest: Statutory

Guidance for CCGs, Dec 2014 • Monitor – Substantive Guidance on the Procurement,

Patient Choice and Competition Regulations, Dec 2013

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References and associated CCG documentation

THCCG Constitution

List of approvals obtained Executive Team – TBC – Jan 2015 Governing Body – TBC – Jan 2015 Audit Committee – TBC – Jan 2015

Recommended review period Annually

Key words contained in document

Conflicts of interest, Clinical Commissioning Groups, Declarations

Is this document fit for the public domain? Y / N Y If No,

why?

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Contents 1 Purpose and scope .......................................................................................................................... 4 2 Standards of business conduct ........................................................................................................ 4 3 Policy Statement .............................................................................................................................. 6 4 Responsibilities ................................................................................................................................ 6 5 Overview .......................................................................................................................................... 7 6 Declaring conflicts of interest ......................................................................................................... 12 7 Managing a declared interest ........................................................................................................ 13 8 The declarations of interest form ................................................................................................... 15 9 Conforming to arrangements for managing conflicts of interest .................................................... 15 10 Interests and gifts ...................................................................................................................... 15 11 Failure to declare a conflicts of interest .................................................................................... 16 12 Fraud and bribery ...................................................................................................................... 16 13 Equality and Diversity Statement .............................................................................................. 16 14 Communication ......................................................................................................................... 16 15 Monitoring, Audit and Evaluation .............................................................................................. 17 16 Transparency in Procurement 16 Appendix 1: Frequency Asked Questions ................................................................................. 21 17 Appendix 2: Declaration of interests form 2012/13 ................................................................... 26 18 Appendix 3: Tower Hamlets CCG declaration of interest register template ............................. 31

Formatted: Normal, Tab stops: Not at 1.16 cm + 15.9 cm

Formatted: Font: (Default) Arial, 10pt, Check spelling and grammar

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1 Purpose and scope

1.1 Purpose

In line with its standards of business conduct this policy sets out how the Tower Hamlets Clinical Commissioning Group (TH CCG) will manage conflicts of interest arising from the operation of the clinical commissioning groups governing body.

The aim of this policy is to provide transparency and assurance that both the organisation and the individuals involved from any appearance of impropriety and demonstrate transparency to the public and other interested parties. The aims of this policy are to:

- enable TH CCG and clinicians in commissioning roles to demonstrate that they are acting fairly and transparently and in the best interest of their patients and local populations;

- ensure that TH CCG operates within the legal framework

- safeguard clinically led commissioning, whilst ensuring objective investment decisions;

- provide the public, providers, Parliament and regulators with confidence in the probity, integrity and fairness of commissioners’ decisions; and

uphold the confidence and trust between patients and GP

1.2 Scope

This policy applies to all individuals, i.e. an employee, group member, member of the governing body, or a member of a committee or a sub-committee of TH CCG, or its governing body,. bidders, contractors, potential contractors, and service providers.

For people contracted to provide services or facilities directly to TH CCG they will be subject to the same requirements as this policy and the requirements will be set out in the contract for their services.

2 Standards of business conduct

2.1 Responsibilities

The governing body of TH CCG has ultimate responsibility for all actions carried out by staff and committees throughout the CCG’s activities. This responsibility includes the stewardship of significant public resources and the commissioning and provision of healthcare to the community.

Therefore as is required by section 14O of the 2006 Act the Clinical Commissioning Group (CCG) will make arrangements to manage conflicts and potential conflicts of interest to ensure that decisions made by the group will be taken, and be seen to be taken, without any possibility of the influence of external or private interest.

CCGs must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contact

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In doing so the governing body will ensure that the organisation inspires confidence and trust amongst its patients, staff, partners, funders and suppliers by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decision-making of the CCG.

2.2 Seven principles of public life

As an integral part of its standards of business conduct and hence in its management of conflicts of interest, TH CCG respects the seven principles of public life promulgated by the Nolan Committee.

The seven principles are:

• selflessness

• integrity

• objectivity

• accountability

• openness

• honesty

• leadership

The governing body has a legal obligation to act in the best interests of TH CCG and in accordance with the CCGs constitution and terms of establishment approved by the NHS Commissioning Board England, and to avoid situations where there may be a potential conflict of interest.

If any such individual has an interest, or becomes aware of an interest, which could lead to a conflict of interests in the event of the TH CCG considering an action or decision in relation to that interest it must be considered as a potential conflict.

Any such interest will be subject to the provisions of the CCGs constitution. This includes GP Practice representatives at locality meetings. For the removal of doubt this means that if you have a conflict of interest you must not be involved in procuring, tendering, managing or monitoring a contract in which as an individual associated with the CCG you have, or may have, an interest.

2.3 Additional documents

The policy should be read in conjunction with the following documents, which also set out generic guidelines and responsibilities for NHS organisations and General Practitioners in relation to conflicts of interests:

• Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions

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• Code of conduct for NHS Managers 2002

• NHS Code of Conduct and Code of Accountability,2004

• The Healthy NHS Board: Principles for Good Governance

• General Medical Council: Good Medical Practice 2006

• NHS Commissioning Board model constitution, April 2012

• Code of Conduct: Managing conflicts of interest where GP practices are providers of CCG commissioned services (NHS Commissioning Board, July 2012)

• NHS England - Managing Conflicts of Interest: Statutory Guidance for CCGs, Dec 2014

• Monitor – Substantive Guidance on the Procurement, Patient Choice and Competition Regulations, Dec 2013

3 Policy Statement

This policy supports a culture of openness and transparency in business transactions. All employees and appointees of TH CCG are required to:

• ensure that the interests of patients remain paramount at all times

• be impartial and honest in the conduct of their official business

• use public funds entrusted to them to the best advantage of the service and service users, always ensuring value for money

• ensure that they do not abuse their official position for personal gain or to the benefit of their family or friends

• Ensure that they do not seek to advantage or further, private or other interests, in the course of their official duties.

4 Responsibilities

Role Responsibilities

CCG Board Governing Body

Be aware of all situations where an individual has interests outside of his / her Contract of Employment or other involvement with the CCG, where that interest has potential to result in a conflict of interest between the individual’s private interests and their CCG duties.

Accountable Officer Chief Officer

Ensure that for every interest declared, either in writing or oral declaration, arrangements are in place to manage the conflict of interest or potential conflict of interests, to preserve the integrity of the CCG’s decision making process.

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Deputy Director of Strategy and Planning

Director of Quality and Performance

Overall responsibility for ensuring that conflicts of interests are logged comprehensively and managed properly to ensure the legality of commissioning decisions and the integrity of the clinicians involved remains undiminished.

All Managers Ensure members of staff are aware of the policy and process to be followed.

All Staff employed or appointed by the CCG and those serving in a formal capacity.

Ensure that they declare a potential conflict between their private interests and their CCG duties.

Declare relevant and material interests to the CCG upon appointment, when a new conflict of interest arises, or upon becoming aware that the CCG has entered into, or proposes entering into, a contract in which they or any person connected with them has any financial or material interest, either direct or indirect.

Familiarise themselves with this policy and comply with the provisions set out in it.

Contractors and people who provide services to the CCG

For contractors and people who provide services to the TH CCG seeking information regarding a procurement, or participating in a procurement, or otherwise engaging with the CCG in relation to the potential services or facilities to the CCG then they will be required to make a declaration of any relevant conflict or potential conflict of interest. Requirements will be set out in the information supporting the procurement.

5 Overview

Below is a flow chart outlining the ways a conflict of interest can be identified and declared.

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5.1 Categories of conflicts of interest

A conflict will arise where an individual’s ability to exercise judgement or act in their role in the commissioning of services is impaired or influenced by their interests in the provision of those services. Monitor – Substantive Guidance on the Procurement, Patient Choice and Competition Regulations, Dec 2013

There are a number of different types of conflicts of interest that individual professionals involved in the decision-making activities of TH CCG might have, or be perceived to have.

These include:

5.1.1 Direct financial interest

A clear conflict of interest arises when an individual involved in taking or influencing the decisions of the TH CCG could receive a direct financial benefit as a result of the decisions being taken.

This may arise as a result of holding an office or shares in a private company or business, or a charity or voluntary organisation that may do business with the CCG

5.1.2 Indirect financial interests

Indirect financial interest arises when a close relative of a director or other key person benefits from a decision of the TH CCG.

As healthcare providers as well as Commissioners, individual healthcare professionals sitting on the governing bodies of the CCG (and their family members or business partners) may have commercial interests in organisations that their commissioning group is already purchasing from or /offer to provide services that the group might procure and fund.

5.1.3 Non- financial or personal interests

These occur where directors or other key persons of TH CCG receive no financial benefit, but are influenced by external factors such as gaining some other intangible benefit or kudos, for example, through awarding contracts to friends or personal business contacts. Even if the individuals leading the TH CCG do not have commercial or other direct interests in particular services or providers, they are likely to have long-standing professional relationships with colleagues to whom they may have allegiances as peers, and with whom they have developed particular ways of working over a period of time.

Personal conflicts could therefore exist when decisions are being taken that would affect such relationships in some way.

5.1.4 Conflicts of loyalty

Decision-makers may have competing loyalties between the TH CCG to which they owe a primary duty and some other person or entity. This could include loyalties to a particular professional body, society or special interest group, and could involve an interest in a particular condition or treatment due to an individual’s own experience or that of a family member.

There is also a specific sub-set to this conflicts of interest category that relates to clinical commissioners acting on behalf of TH CCG where perceived conflicts between an individual’s professional duties or responsibilities when acting on behalf of a whole

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population as a commissioner, and of individual patients as a primary care provider. The Code of Conduct, July 2012 applies

5.2 Examples of conflicts of interest

It is not possible, or desirable, to define all instances in which an interest may be a real or perceived conflict. It is for each individual to exercise their judgement in deciding whether to register any interests that may be construed as a conflict. However, interests that may impact on the work of the governing body and should be declared include:

• any directorships including non-executive directorships held in private companies or public

• limited companies (with the exception of those of dormant companies) of companies likely to be engaged with the business of the clinical commissioning group

• ownership or part ownership of companies, businesses or consultancies which may seek to do business with the CCG

• previous or current employment or consultancy positions

• voluntary or remunerated positions, such as trusteeship, local authority positions, other public positions

• membership of professional bodies, mutual support organisations or a position of trust in a charity or voluntary organisation in the field of health and social care

• gifts or hospitality offered to you by external bodies and whether this was declined or accepted in the last twelve months

• receipt of research funding / grants from the CCG or related parties

• interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the CCG must be declared)

• formal interest with a position of influence in a political party or organisation

• current contracts with the CCG in which the individual has a beneficial interest

• any other employment, business involvement or relationship or that of a spouse or partner that conflicts, or may potentially conflict with the interests of the CCG

• religious activities or interests that could impact on decisions impacting on primary care , for example sexual health services

• any other conflicts that are not covered by the above,

•

As a general rule:

A perception of wrongdoing, impaired judgement or undue influence can be as detrimental as any of them occurring

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If in doubt the individual concerned should assume that a potential conflict of interest exists and seek advice from the CCG Governance lead

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6 Declaring conflicts of interest

Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of the TH CCG, in writing to the governing body, as soon as they are aware of it and in any event no later than 28 days after becoming aware.

Where an individual is unable to provide a declaration in writing, for example, if a conflict becomes apparent in the course of a meeting, they will make an oral declaration before witnesses, and provide a written declaration as soon as possible thereafter.

Examples of where this could occur include where an individual member, employee or person providing services to the CH Clinical CCG is aware of an interest which:

a) has not been declared either in the register or orally they will declare this at the start of the meeting.

b) has previously been declared in relation to the scheduled or likely business of the meeting. The individual concerned will bring this to the attention of the chair of the meeting, together with arrangements which have been confirmed with the Accountable Officer for the management of the conflict of interest or potential conflict of interest.

For contractors and people who provide services to the TH CCG seeking information regarding a procurement, or participating in a procurement, or otherwise engaging with the CCG in relation to the potential services or facilities to the CCG then they will be required to make a declaration of any relevant conflict or potential conflict of interest- See Appendix 2b. Requirements will be set out in the information supporting the procurement.

If in doubt the individual concerned should assume that a potential conflict of interest exists and seek advice from the CCG Governance lead

There are several mechanisms for making a declaration of interest. These include:

6.1 Annual declaration

The declaration of conflicts of interest is an annual process which takes place at the start of the corporate year. This includes a review and the incorporation of any resulting changes to this policy.

6.2 Declarations of Interest at meetings

The agenda (both public and confidential agenda) for meetings of the CCG Board and also its committees will contain a standing item at the commencement of each meeting, requiring members to declare any interests relating specifically to the agenda items being considered.

Example: Item1: Welcome, apologies and declarations of interest

If during the course of a meeting, an interest not previously declared is identified, this shall be declared.

Board and committee members must be specific when declaring interests. They should state which agenda item the potential conflict of interest relates to and the nature of that conflict.

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Any declarations of interests, and arrangements agreed in any meeting of the TH CCG, committees or sub-committees, or the governing body, the governing body’s committees or sub-committees, will be recorded in the minutes.

6.3 Registering conflicts of interest

TH CCG holds and maintains an electronic register of conflicts and potential conflicts of interest of;

• the members of the group

• the members of its governing body (i.e. its Directors, Lay members and CCG Board members)

• the members of its committees or sub-committees and the committees or sub-committees of its governing body

• its employees

• all others if requested by the Accountable Officer as part of the CCGs annual review of interests

The electronic register captures all the details declared on the conflicts and potential conflicts of interest form and additionally include details on the history of the conflict / potential conflict including the agreed arrangements for the management of the conflict and the expired date and circumstances of the conflict / potential conflict.

Maintenance of the TH CCG electronic register, including scanning and secure storage of the source declaration forms is the responsibility of the CCG Governance lead who ensures that

• details of any conflicts / potential conflicts of interest are recorded within 1 week of the declaration and,

• that the register is reviewed on a quarterly basis by the TH CCG governing body with oversight and assurance provided through the CCGs Audit Committee who review the register of declarations on an annual basis

The format of the register can be seen at Appendix 23: Tower Hamlets CCG declaration of interest register template.

To ensure TH CCG addresses access needs of all stakeholders, such as individuals without internet access, individuals may view the register at the CCG’s Headquarters upon invitation by the CCG.

7 Managing a declared interest

Where an interest is significant or when the individual or a connected person has a direct financial interest in a decision, the individual should not take part in the discussion or vote on the item and should consider leaving the room when the matter is discussed.

The Chair of the meeting may ask that a member leaves the room if they have a significant interest or a direct financial interest in a matter under discussion.

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The Chair of the meeting will, in discussion with the Accountable Officer, determine how any declared conflicts should be managed and inform the member of their decision.

Where no arrangements have been confirmed the Chair of the meeting may require the individual to withdraw from the meeting or part of it. The individual will then comply with these arrangements.

7.1 Taking a decision in the event of a conflict of interest

If the Chair or member/members has been disqualified from participating in the discussion on any matter and/or from voting on any agenda item by reason of a declaration of a conflict of interest that person shall no longer count towards the quorum.

In making this decision the Chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the TH CCG standing orders Constitution.

If a quorum is then not available for the discussion and/or the passing of a resolution on that matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interests, the chair of the meeting shall consult with the Accountable Officer on the action to be taken.

This may include:

a) requiring another of the TH CCG committees or sub-committees, the CCGs governing body or the governing body’s committees or sub-committees (as appropriate) which can be quorate to progress the item of business, or if this is not possible,

b) inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the governing body or committee / sub-committee in question) so that the group can progress the item of business

i. a member of the TH CCG who is an individual

ii. an individual appointed by a member to act on its behalf in the dealings between it and the CCG

iii. a member of a relevant Health and Wellbeing Board

iv. a member of a governing body of another clinical commissioning group

These arrangements must be recorded in the minutes.

7.2 Chair responsibility for declaring conflict of interest during a meeting

Where the Chair of any meeting of the TH CCG including committees, sub-committees, or the governing body and the governing body’s committees and sub-committees, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and they should not Chair for that particular item. The deputy chair will act as chair for the relevant part of the meeting

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Where arrangements have been confirmed for the management of the conflict of interests or potential conflicts of interests in relation to the Chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the deputy chair may require the chair to withdraw from the meeting or part of it. Where there is no deputy chair, the members of the meeting will select one.

8 The declarations of interest form

Appendix 2a2 shows the form for recording conflicts of interest and potential conflicts of interest for an individual member, employee or person providing services to the TH CCG.

Appendix 2b shows the form for recording conflicts of interest and potential conflicts of interest for bidders, contractors, potential contractors, and service providers.

The information provided will be processed in accordance with data protection principles as set out in the Data Protection Act 1998.

Data will be processed only to ensure that the board members act in the best interests of the CCG and the public and patients the group was established to serve. The information provided will not be used for any other purpose.

Signing the declaration form will also signify that you consent to your data being processed for the purposes set out in this policy.

9 Conforming to arrangements for managing conflicts of interest

In any transaction undertaken in support of the TH CCG exercise of its commissioning functions (including conversations between two or more individuals, e-mails, correspondence and other communications), individuals must ensure, where they are aware of an interest, that they conform to the arrangements confirmed for the management of that interest.

Where an individual has not had confirmation of arrangements for managing the interest, they must declare their interest at the earliest possible opportunity in the course of that transaction, and declare that interest as soon as possible thereafter. The individual must also inform either their line manager (in the case of employees), or the Accountable Officer of the transaction.

The Accountable Officer will take such steps as deemed appropriate, and request information deemed appropriate from individuals, to ensure that all conflicts of interest and potential conflicts of interest are declared.

10 Interests and gifts

Interests and gifts will be recorded on the register of interests and register of gifts and hospitality, which will be maintained by the Governance lead / Company Secretary on behalf of the Accountable Officer.

The register will be accessible by the public and inspection of the register of board members interests will be encouraged, as appropriate.

Board members should not use confidential information acquired in the pursuit of their role to benefit themselves or another connected person.

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11 Failure to declare a conflicts of interest

If any members or employees fail to declare an interest, or participates in a decision making process where special favour is shown to unfairly award a contract, or abuse their official position or knowledge for the purpose of benefit to themselves, family or friends, then after investigation, if proven will result in appropriate disciplinary action for gross misconduct and referral to the appropriate professional regulatory body.

12 Fraud and bribery

It is an offence under the Bribery Act 2010 (previously Prevention of Corruption Acts 1906 and 1916) for an employee to accept any inducement or reward for doing or refraining from doing anything, in his or her official capacity, or corruptly showing favour, or disfavour, in the handling of contracts.

Furthermore the Bribery Act 2010 goes further and created a corporate offence for organisations who fail to prevent a bribe. This offence requires an organisation to demonstrate that they have “adequate procedures” in place to prevent a bribe.

Staff who fail to declare a conflict of interest and who benefit as a result may be subject to an investigation by the Local Counter Fraud Specialist for fraud and bribery offences under the Fraud Act 2006 and or the Bribery Act 201

13 Equality and Diversity Statement

The organisation is committed to ensuring that it treats its employees fairly, equitably and reasonably and that it does not discriminate against individuals or groups on the basis of their ethnic origin, physical or mental abilities, gender, age, religious beliefs or sexual orientation. An Equality Impact Assessment has been completed for this policy and does not identify areas of concern.

If you have any concerns or issues with the contents of this policy or have difficulty understanding how this policy relates to you or your role, please contact the Governance lead / Company Secretary.

14 Communication

TH CCG will ensure that all employees and decision-makers are aware of the existence of this policy through, for example;

• introduction to the policy during local induction for new starters to the organisation

• annual reminder of the existence and importance of the policy via internal communication methods

• annual reminder to update declaration forms sent to all governing body members

• annual report to the CCG Board

Staff should also refer to their respective professional codes of conduct relating to the declaration of conflicts of interest.

TH CCG will view instances where this policy is not followed as serious and may take disciplinary action against individuals as appropriate, which may result in dismissal from employment or removal from elected positions.

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Declarations of interest made by the TH CCG Board members are published within the CCGs annual report.

The TH CCG publishes its conflicts of interest register on its website and is updated on a quarterly basis and in line with assurance process timetable.

15 Monitoring, Audit and Evaluation

The policy will be reviewed annually by the Audit Committee.

Staff and decision-makers will be reminded of the policy and register of interests at least annually.

The Governance lead / Company Secretary will review register entries on a regular basis and take any action necessary as identified by the review.

16.0 Transparency in Procurement 16.1 The CCG recognises the importance in making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made. The CCG will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers. 16.2. The CCG will publish a procurement strategy approved by its Governing Body which will ensure that: • We will ensure that we will engage with all our partners, including the public, Health and Well Being Board, Local Authority and NHS colleagues through a thorough dialogue to ensure that any decisions have been robustly consulted on to ensure that all opinions and ideas are heard and incorporated, where appropriate. • In line with the three main principles of procurement law ,service redesign and procurement processes are conducted in an open, transparent, non -discriminatory and with equal treatment. This includes ensuring that the same information is given to all. • details of contracts, including contract value, are published on the CCG website. This includes details relating to services commissioned through Any Qualified provider (AQP) and details of the providers themselves • In line with the commitment to transparency of GP earnings, there will be a new contractual requirement for GP practices to publish on their practice websites by 31 March 2016 the mean net earnings of GPs in their practice relating to 2014/15 financial year. 16.3 Copies of the CCG’s procurement strategy will be available on the CCG’s website. 16.4 Register of procurement decisions The CCG holds and maintains a register of its procurement decisions taken. The register includes: • the details of the decision

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• who was involved in making the decision i.e. governing body or committee members with decision making responsibility (note: the awarding of a contract is prohibited where the integrity of the award has been, or appears to have been affected by a conflict of interest) • a summary of any conflicts of interest in relation to the decision and how this is managed by the CCG. • decisions regarding the approach to procurement for each separate procurement will be published on the CCG’s website and made publically available to all • The register of procurement decisions forms part of the CCGs annual accounts and is signed through the external auditors processes 16.5 Procurement decisions relating to primary medical care • Procurement decisions relating to the commissioning of primary medical services for both joint commissioning and delegated commissioning arrangements (ref ‘Next steps towards primary care co-commissioning’; http://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf ) are undertaken by a committee of the CCGs Governing Body • The decision making committee is constituted to ensure that the majority of its membership is held by lay and executive members. • There is a standing invitation to representatives of the CCGs local Healthwatch and Health and Wellbeing Board. The representatives do not form part of the membership of the committee albeit they are able to attend Primary Care Commissioning Committee meetings, whether public meetings or those deemed commercial in confidence. • Lay members of the committee undergo a formal training programme developed by NHS England to assist them with their role within the committee • Where appropriate the CCG employs the support of Commissioning Support Services (CSS) in deciding the most appropriate procurement route and to manage conflicts of interest in order to preserve integrity of decision making • Any conflicts of interest that arise in connection with decisions to be made by the committee are considered on an individual basis • The arrangements for decisions relating to primary medical care do not preclude GP participation in strategic discussions on primary care issues, subject to the appropriate management of conflicts of interest and detailed in this policy. They apply to decision making on procurement issues and the process leading up to the decision. • NHS England provide oversight to the CCG to ensure that the CCG is meeting its statutory duties in its management of conflicts of interest. • Questions to be considered by the committee when commissioning services from GP practices, including provider consortia, or organisations in which GPs have a financial interest are shown in the Procurement template at Appendix 2c 16.6 External Scrutiny of Conflicts of Interest Management

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● The registers will form part of the CCG’s annual accounts and will thus be signed off by external auditors

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16 Appendix 1: Frequency Asked Questions

16.116 What is a conflict of interest?

Conflicts arise when the interests of governing body members, or persons connected to them, are incompatible or in competition with the interests of the clinical commissioning group. Such situations present a risk that governing body members will make decisions based on these external influences, rather than the best interests of the patients and public on whose behalf they are commissioning services or considering service redesigns.

A conflict of interest could be defined as any situation in which a governing body member’s personal interests or responsibilities may, or may appear to, influence the governing body member’s decision-making.

The most common types of conflicts of interest include:

• direct financial interest

• indirect financial interest

• non-financial personal interests

• conflicts of loyalty

16.2 Direct financial interest

The most easily recognisable form of conflict of interest arises when a governing body member obtains, or is perceived to obtain, a direct financial benefit over and above the agreed remuneration and terms of service package agreed by the remuneration committee.

Examples include:

• the award of a contract to a company or other business with which a governing body member is involved

• the sale of assets at below market value to a governing body member.

The General Medical Council’s guidance is clear in that:

You must be honest in financial and commercial dealings with employers, insurers and other organisations or individuals. In particular:

“before taking part in discussions about buying or selling goods or services, you must declare any relevant financial or commercial interest that you or your family might have in the transaction.”

Additionally, the General Medical Council’s guidance on managing conflicts of interest states:

“If you have financial or commercial interests in organisations providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients”.

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16.3 Indirect financial interest

This arises when a close relative of a governing body member benefits from the decisions of the clinical commissioning group. Governing body members will benefit indirectly if their financial affairs are bound with those of the relative in question through the legal concept of ‘joint purse’, as would be the case if the relative were the spouse, partner, dependent child of the governing body member, or directly connected person in some other way. For example, the governing body member being involved in a decision to award a contract to an organisation where the member’s spouse is a director.

16.4 Non-financial or personal conflicts

These occur where governing body members receive no financial benefit, but are influenced by external factors. For instance:

• to gain some other intangible benefit, power or kudos • nepotism towards family members with whom the governing body member does not

have a ‘joint purse’, e.g. parent, sibling, non-dependent child • awarding contracts to friends or personal business contacts

16.5 Conflict of loyalties

Governing body members may have competing loyalties between the clinical commissioning group to which they owe a primary duty and some other person or entity, including their GP practice and patients.

Governing body members should also avoid using knowledge gained in other roles to influence decisions and thereby acquire a competitive advantage over other service providers.

16.6 When might a conflict of interest arise?

Conflicts of interest might arise where an individual’s personal interests and/or loyalties, or those of a connected person, conflict with those of the clinical commissioning group. Such conflicts may create problems such as inhibiting free discussion, which could:

• result in decisions or actions that are not in the interests of the clinical commissioning group and the public it was established to serve

• risk the impression that the clinical commissioning group has acted improperly.

It is not possible, or desirable, to define all instances in which an interest may be a real or perceived conflict. It is for each individual to exercise their judgement in deciding whether to register any interests that may be construed as a conflict. Individuals can seek guidance from the company secretary, but should decide to declare when in doubt.

16.7 Why has a conflicts of interest policy for clinical commissioning group governing bodies?

The governing body, and individual directors, of an NHS entity have a legal obligation to act in the best interests of the organisation, in accordance with the organisation’s governing document, and to avoid situations where there may be a potential conflict of interest. As such, there are requirements for governing body members to register personal financial and non-financial interests which may be perceived as conflicting with that overriding duty.






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16.7.1 Benefit to clinical commissioning group

With proposed responsibility for approximately 60% of the NHS budget, clinical commissioning groups need to operate effectively and efficiently and with an appropriate level of transparency to ensure accountability. It is essential for maintaining public trust and confidence that clinical commissioning groups work within a robust ethical framework, and are seen to act in accordance with the high standards expected of healthcare professionals.

Conflicts of interest, if not handled appropriately, may present problems such as:

• inhibiting free discussion

• resulting in decisions or actions that are not in the interests of the clinical commissioning group, public and patients

• risking the impression that the clinical commissioning group has acted improperly.

16.7.2 Benefit to governing body members

Decisions made under a conflict of interest may be legally challenged and could result in personal liability for the governing body member. There are clear benefits to be derived from establishing, and adhering to, a conflict of interest policy to protect both the organisation and the individuals involved from any appearance of impropriety.

16.7.3 Benefit to the public

For public trust and confidence to be maintained, both real and perceived conflicts need to be acknowledged and managed.

Where the conflicts of interest policy requires members to withdraw from meetings, the company secretary should take care to ensure that edited minutes are provided to that member to ensure that any information related to the matter in question is not disclosed, and to avoid presenting any further instances of conflict, real or perceived.

Any conflicts of interest policy should be accompanied by policies on receiving gifts and hospitality and anti-bribery procedures. All policies should be publicly available along with a regularly updated register of interests and gifts, offered and accepted, for governing body members and staff.

Maintaining public trust and confidence will be essential if the public and patients are to believe that the NHS arrangements are working on their behalf. The General Medical Council’s Good Medical Practice: Duties of a Doctor states that:

“Patients must trust doctors with their lives and health……You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions”.

16.8 What to do if you face a conflict of interest

All governing body members are required to declare their interests in relation to any items on the agenda at the start of each governing body or committee meeting. Where the conflict is material to the discussion of the governing body, that member shall withdraw from discussions pertaining to that agenda item, the conflict and the action will be recorded in the minutes of the meeting and the register of interests updated accordingly.





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it is the responsibility of the Company secretary to monitor quorum and advise the chair accordingly to ensure it is maintained throughout the discussion and decision of the agenda item. should the withdrawal of the conflicted director result in the loss of quorum, the item cannot be decided upon at that meeting.

Where permitted under the clinical commissioning group’s constitution or the conditions of its establishment, the governing body has the power to waive restrictions on any clinical professional governing body member participating in governing body business, where to authorise such a conflict would be in the interests of the clinical commissioning group. The application of a waiver can, therefore, be used in the following situations:

• a member of the governing body is a clinical professional providing healthcare services to the clinical commissioning group that do not exceed the average for other practices and NHS entities commissioned to provide services by the clinical commissioning group; or

• where the governing body member has a pecuniary interest arising out of the delivery of some professional service on behalf of the clinical commissioning group, and the conflict has been adjudged by the chair and the governance lay member not to bestow any greater pecuniary benefit to other professionals in a similar relationship with the clinical commissioning group.

Where the chair and the governance lay member have approved the use of the waiver, the chair must have discussed it with the chief executive before the meeting. In such circumstances where the waiver is used, the governing body member:

• must disclose his/her interest as soon as is practical at the start of the meeting

• may participate in the discussion of the matter under consideration; but

• must not vote on the subject under discussion.

The minutes of the meeting will formally record that the waiver has been used, and that this policy and the governing document provisions have been observed in managing that authorised conflict. Where a member has withdrawn from the meeting for a particular item, the company secretary will ensure that the minutes for that member do not contain such information that may compound the potential conflict, but do not unnecessarily disadvantage the member in their performance of their functions and legal responsibilities.

16.9 Decisions taken where a governing body member has an interest

In the event of the governing body having to decide upon a question in which a governing body member has an interest, all decisions will be made by voting, with a [simple majority] [two thirds majority] required. A quorum must be present for the discussion and decision; interested parties will not be counted when deciding whether the meeting meets quorum. Interested governing body members must not vote on matters affecting their own interests, even where the use of the waiver has been approved by the chairman and used.

All decisions under a conflict of interest will be recorded by [the company secretary] and reported in the minutes of the meeting and the register of decisions. The report will record:

• the nature and extent of the conflict

• an outline of the discussion


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• the actions taken to manage the conflict

• use of the waiver and reasons for its implementation.

Where a governing body member benefits from the decision, this will be reported in the annual report and accounts, as a matter of best practice.

All payments or benefits in kind to governing body members will be reported in the clinical commissioning group’s accounts and annual report, with amounts for each governing body member listed for the year in question.

Independent external mediation will be used where conflicts cannot be resolved through the usual procedures.

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17 Appendix 2a2: Declaration of interests form 2012/13 for members / employees template Name (please PRINT):

Organisation:

Position within or relationship with the CCG or NHS England:

Interests

Type of interest Details

(if no interest to declare please state ‘none’)

Personal interest or that of a family member, close friend or other acquaintance?

Roles and responsibilities held within members practices

Directorships, including non-executive directorships, held in private companies or PLCs

Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and/or NHS England

Shareholdings (more than 5%) of companies in the field of health and social care

Positions of authority in an organisation (e.g. charity or voluntary organisation) in the filed of health and social

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care

Any connection with a voluntary or other organisation contracting for NHS services

Research funding/grants that may be received by the individual or any organisation they have an interest or role in

Other specific interest

Any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG and / or NHS England

To the best of my knowledge and belief, the above information is complete and correct.

I undertake to update as necessary the information provided and to review the accuracy of the information provided regularly and no longer than annually. I give my consent for the information to be used for the purposes described in the CCG’s constitution and published accordingly

Signed:………………………………………………………………………………………….

Date: ……………………………………………………………………………………………

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Appendix 21b Declaration of interests for Bidders, Contractors, Potential Contractors, and Service Providers template – NHS Tower Hamlets Clinical Commissioning Group Name of Relevant Organisation

Interests Type of Interest Details Provision of services or other work for the CCG or NHS England

Provision of services or other work for any other potential bidder in respect of this project or procurement process

Any other connection with the CCG or NHS England,whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members or employees judgements, decisions or actions

Name of Relevant Person

(complete for all relevant persons)

Interests Type of Interest Details Personal interest or that of a family

member, close friend or other acquaintance?

Provision of services or other work for the CCG or NHS England

Provision of services or other work for any other potential bidder in respect of this project or procurement process

Any other connection with the CCG or NHS England, , whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members or employees judgements, decisions or actions

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information. Name: Signed: On behalf of: Date

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Appendix 2c1c: Procurement Template: to be used when commissioning services from GP practices, including provider consortia, or organisations in which GPs have a financial interest NHS Tower Hamlets Clinical Commissioning Group Service Question Comment / Evidence How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities? How does it comply with the CCG’s commissioning obligations?

How have you involved the public in the decision to commission this service?

What range of health professionals have been involved in designing the proposed service?

What range of potential providers have been involved in considering the proposals?

How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?

What are the proposals for monitoring the quality of the service?

What systems will there be to monitor and publish data on referral patterns?

Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers which are publicly available? Have you recorded how you have managed any conflict or potential conflict?

Why have you chosen this procurement route?

What additional external involvement will there be in scrutinising the proposed decisions?

How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process and award of any contract?

Additional question when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) or direct award (for services where national tariffs do not apply) How have you determined a fair price for the service?

Additional questions when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) where GP practices are likely to be

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qualified providers How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?

Additional questions for proposed direct awards to GP providers What steps have been taken to demonstrate that the services to which the contract relates are capable of being provided by only one provider?

In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract?

What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?

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Appendix 3: Tower Hamlets CCG declaration of interest register template

Name

CCG Role: 1 – CCG Board Member

2 – GP 3 – Member of CCG Management Team

4 - Other

Name of Individual / Company / Voluntary Body /

Organisation Nature of Business/

Organisation Nature of Interest/Comments

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Date of meeting Tuesday, 27 January 2015 P

Agenda item 3.3

Title of report: Community Health Services (CHS) update

Author(s): Louise Morgan – Programme Manager


Maggie Buckell – Registered Nurse member

Nigel Woodcock – Programme Director

Executive summary The purpose of this report to the Governing Body is to provide a summary of the reprocurement of Community Health Services.

Recommendation

Information Approval To note x Decision

Conflicts of Interest There is a robust programme governance structure in place to ensure a rigorous approach to managing conflicts of interest is embedded across the programme.

Key issues Once the procurement process is completed, the newly awarded service will be delivered from April 2016.

Report history Information developed by the CHS Programme Management Office informs this Governing Body report.


Patient and public engagement events will form an integral part of the programme’s development as described in the report.


This programme effects BAF risk 3.2 – integrated services to meet individual needs


Reprocurement of CHS will have a beneficial impact for all patients.

Resource requirements n/a

Next steps The Governing Body is asked to: • NOTE the progress of the CHS reprocurement programme and

key workstreams supporting its progress.

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Community Heath Services in Tower Hamlets

Report Tower Hamlets CCG Governing Body

27 January 2015

Community health services help people get well and stay well without having to travel too far from home.

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People in Tower Hamlets are telling us community health services need to improve. The current contract is due to expire in March 2016.

Excellent provision of some services, such as diabetes Good support for some people with long term conditions Services are locally accessible Primary, secondary and social care services aren’t communicating or working together as well as they should Variable patient experience, with specific issues around initial access, care co-ordination, follow through and transition Lack of an integrated care record Variable focus on prevention and early diagnosis

Themes from patient feedback:

Why are we procuring?

It’s a nightmare if you’re a carer trying to work your way through the system… Who provides it? What assessment do I need? My son has a personal care package, that took five assessments because everybody has their bit of the budget. Community workshop 31/05/2014

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Most community services currently managed by Barts Health NHS Trust. Some community services managed by other providers are excluded.

• Coordination Function, such as the out of hours and single point of access service, advocacy and interpreting

• Early years and children’s services, such as speech and language therapy, safeguarding teams, audiology and children’s community nursing services

• Adult rehabilitation and therapy services, such as psychology teams, audiology, inpatient beds and physiotherapy

• Adult recovery and prevention services, such as adult community nursing services, foot health, stroke rehabilitation, diabetes and cardio-vascular

Services being procured:

What services are we procuring?

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Engagement undertaken so far

Engagement activity so far: • Desktop research • Community workshop (31/5/2014) • Health and Wellbeing Forum (9/7/2014) • CCG Organisational Development Session

(22/7/2014) • Six meetings with Healthwatch, including

community health event (14/8/2014) • AGM (02/09/2014) • Programme events (10/6/2014 & 16/11/14) • 13 bulletins issued to staff and board

members • Updates via GP e-bulletin and intranet • Written updates to Barts Health CHS staff • Clinical Commissioning Forum (5/8/2014) • Locality meetings (at least one in each) and

locality chairs meeting

Between March and September 2014 the CCG engaged with the community to confirm a preferred clinical approach and agreed the method of procurement.

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Method of procurement We are bringing together patients, clinicians and a number of potential providers to co-design services and come up with innovative solutions that best meet the needs of the community. This type of procurement is called competitive dialogue.

Outcomes-based commissioning: Paying for health and care services based on delivering outcomes that are important to people who use them.

Competitive dialogue: Ongoing discussions with a number of potential providers in response to a commissioner’s outline requirements. This enables patients, clinicians, commissioners and providers to co-design services. Only when a provider’s proposals are developed sufficiently are tenderers invited to submit competitive bids.

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The preferred clinical approach

All services work together to give patients personalised care

Coordination function

• Patients access community health services through a single entry point • All clinicians use a shared IT system to streamline patient records • Services are accessible in and out of hours • Dedicated staff help people to move from one service to another • Patients have personalised patient care plans • Services are planned based on what patients need and capacity available

Joint working between social care, public health and mental health

Services for people who need longer term care for chronic / long term conditions

Services for people who need shorter term rehabilitation care to get out of hospital and stay

out of hospital

Early years and children’s services

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Procurement timeline

Develop service specification (patient outcomes)

Competitive dialogue with providers to co-design services

Review final bids and award contract

Mobilise new services to start on 1 April 2016

Involve / engage / co-design

Service design finalised

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Engagement

2. Engagement with the community to design specification

3. Patients / carers recruited to be involved in procurement process

1. Patient representative group formed to advise on and support with engagement throughout the process

4. Patients / carers involved in ongoing co-design of services with provider

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Thank you

Questions?

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Item # Title Presenter Author Enc.

4.1 Audit Committee activity summary Mariette Davis – Lay Member Governance

Justin Phillips – Governance and Risk Manager

Q

Update and key achievements

This report provides an update to the Governing Body of the Audit Committee that was held January 6 2015.

Governance

- Primary Care Co-commissioning

The proposed governance arrangements for the management of conflicts of interest for CCG Primary Care Co-commissioning were discussed and reviewed prior to their inclusion in the submission to NHS England on January 9 2015.

- CHS

The implementation of the CHS phase II governance arrangements were presented, including the arrangements for managing the programme’s conflicts of interest.

- Procurement

The Committee reviewed the CCGs current procurement processes and delegated from the GB authorisation limits for both Committees and individuals.

Internal Audit

The Audit Committee received and discussed the internal audit and counter fraud progress reports for the CCG, and the CSU assurance plan. The absence of Counter Fraud work within the CSU was again noted and the plan is to invite NHS Protect to the next Audit Committee and to continue to endeavour to secure proactive counter fraud work where the risk of fraud is at its greatest,

Finance

Month 6 risk schedule reviewed.

Year end accounts and Annual Report timetable

The Annual Report and Accounts timetable was discussed and meetings were agreed in order that the NHSE submission date of 29 May 2015 could be achieved.

Waivers

Waivers of standing orders that had been authorised by either the CFO or the CO were presented.to the Audit Committee in accordance with the CCG’s governance procedures

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Next meeting The next meeting of the Audit Committee is March 23 2015

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Date of meeting January 27 2015 R

Agenda item 4.2

Title of report: Transformation and Innovation Committee (TIC) Summary from 9th December 2014 and 13th January 2015

Author(s): Maggie Buckell

Presented by:

Maggie Buckell - Registered Nurse, Member of Governing Body and Chair of the Transformation and Innovation Committee (TIC)

Summary

9th December TIC Business cases from the following programme areas were approved in principle subject to a prioritisation exercise to be undertaken at the TIC in February:

• Integrated care • Planned care • Children and Young People • Maternity • Prescribing

13th January TIC Business cases from the following programme areas were approved in principle subject to a prioritisation exercise to be undertaken at the TIC in February:

• Long term conditions • Urgent care • Cancer • Quality in General Practice • Renal Clinical Assessment and Advice Service business cases

The Committee sought further clarity regarding the following business cases: (details below)

• Personal health budgets • Mental health • Last years of life

Information X

Approval To note Decision

Conflicts of Interest Victoria Tzortziou-Brown declared a possible conflict of interest due to her role as a GP and employment by Barts.

Catherine Boyle was not present at the January Committee meeting but had reviewed the business cases for comment; she declared a conflict in relation to the Cancer business case due to her work with Macmillan Cancer Support.

Key issues Mental health business case The Committee agreed with the principle of the investments proposed and commitment to the planning guidance, however, it was recommended that the financial figures be refined as there is too much dependence on contract negotiations. The proposals need

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to be prioritised and scaled back based on what will be delivered against QIPP; if this is achieved then further funding can be agreed. Richard and Henry to meet to finalise investments and this will be circulated to Committee members for comments and approval. Personal Health budgets business case The Committee approved the business case subject to clarity regarding the 90k recurring costs for Continuing Health Care (CHC) operational costs for children and adults: - It was noted that the Local Authority already provide a direct payments service; need

to ensure there isn’t duplication of provision. - There was uncertainty as to why the funding has been requested as recurrent: it

was suggested that the 90k should be on a non-recurrent basis until the outcomes of the proposed pilots are known; these pilots will determine the level of future funding needed.

- The Committee are keen to have an integrated system that provides a person centric record rather than the proposed delivery model put forward by CSU (as a separate system).

Last years of life The business case was approved (in principle) with the exception of the Specialist Palliative Care Social Worker Role. The Committee felt that this should be part of business as usual for the team, with funding released via the PbR tariffs. Prioritisation of investments Business cases that have been approved (in principle) will be subject to a prioritisation exercise to be undertaken at the February TIC meeting. Currently, there are approximately £9m in savings identified, but this is offset against approximately £6.5m of investments. There is scope to fund certain schemes on a non-recurrent basis using this year’s budget, leaving a funding gap of approximately 800k. The prioritisation exercise will enable the Committee to review and prioritise all investments in line with QIPP savings.

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4.3 Finance, Performance and Quality Committee

Archna Mathur and Henry Black

Shuma Begum S


Part 1: Quality and Performance

Review The committee reviewed the Quality and Performance report. The highlights of this are reported in the performance and quality report to the governing body. Additional items included:

• Review of the November 2014 Service Alerts. • Review of quality assurance visits undertaken to Barts Health. • Review of outputs from the Safeguarding Adult’s Committee. • Review of the Barts Health Quarter 1 CQUIN. • Review of the delayed discharge of Medically Fit patients at Royal London Hospital. • Review of Barts Health Mortality Alert for Patients following Therapeutic Endoscopic

Procedures for Biliary Tract. • Review of the Joint Quality dashboard for Nursing and Residential Homes.

Part 2: Finance and Activity The committee reviewed the Finance & Activity report. The highlights of this are reported in the F&A report to the governing body. Particular discussion points included:

• Continued over-performance on the Barts Health contract, with underlying issues including possible over-charging on AHP activity. This has been challenged.

• Investigation into apparent increases in unit cost in comparison to previous years, which could indicate counting and coding changes – should only happen by negotiation and mutual agreement.

• Under-delivery of QIPP is being investigated. The target cohort appear to be reporting improvements in reductions in emergency admissions, but the £ impact is less than expected.

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Locality Board Chairs Summary


4.4 Locality Chairs Board Jane Milligan Radha Gurung T

Update and key issues The Locality Chairs Board meeting was held on 20 January 2015 where a number of items were discussed including: Locality Chairs update North West locality - London Independent Hospital: On the few occasions that patients have been referred to

various clinics (Orthopaedics, Gastroenterology, etc.) at the London Independent, they have been sent back from the outpatient’s clinic without being seen to. Ahead of raising this with the hospital, the GPs would like a clearer understanding of the contractual agreements.

- Community nursing: referrals made to the community nursing team are not being picked up.

South East locality - Discharge planning: RLH are consistently producing poor discharge plans, especially for

elderly / vulnerable patients, who are often readmitted as a result.

- High risk A&E attenders DES: In one of the practices, 20 patients have been placed under the care plan to be monitored. These are reviewed on a quarterly basis but there are no significant changes as only 2 out the 18 are frequent A&E attendees. The practice therefore feels that the DES is ineffective as there is no evidence to suggest that it stops unplanned admissions.

- 4 Claims validations (part of NIS): So far only one claims validation has been completed

and there is not enough information on whether the remaining 3 needs to be completed. Barts Health CQC Inspection Following the CQC’s ‘First Wave’ inspections last year where the Trust was inspected as a whole, the CQC is now embarking on a second round of visits where all Trusts in London will need to be assigned a star rating by December 2015. In line with this, CQC visited Whipps Cross in November 2014 and will be visiting Royal London and Newham between 21 January – 25 January. An action plan will be put in place following the CQC’s findings to improve the quality.

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CHS re-procurement A brief update was provided on the CHS re-procurement, outlining the timeline for each of the stages. Primary care co-commissioning A brief update was given on the progress of primary care co-commissioning. Service alerts Some of the locality chairs raised concerns around how different types of alerts are being submitted into the same portal which does not seem to be the best approach. They were reassured that it is better to have one system to reduce the confusion and have a clearer oversight of the different themes. It is not the GP’s responsibility to ascertain which groups the alerts fall under. In light for this, plans are underway to hold an educational / informative session around service alerts which will be delivered by Bumi Akinmutande.

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Executive Committee Summary


4.5 Executive Committee

Jane Milligan Radha Gurung U

Update and key issues The Executive Committee meeting was held on 20 January 2015 where the following key items were discussed: Director of Performance and Quality role review It was recognised the remit of this role has increased and based on this the Executive committee approved the review. Policies Other leave: This refers to all other types of leave excluding annual leave. The policy outlines the process and the number of days that the staff is entitled to take. It has been approved by SMT and the Executive committee. Secondment: articulates process for internal and external secondment of staff. Approved by Executive committee. Operating plan Mary Morgan attended the meeting to seek permission from the Executive committee on the direction of travel. All data relating to constitution standards will need to be submitted by 28 January 2015. Prior to the submission, the data will be reviewed by Jane. Primary care co-commissioning governance Conflicts of interest policy: Section 16 relating to transparency around the procurement process requires a register of decisions and proforma for any GPs bidding for the service. To be updated and uploaded onto the website. Constitution update: The updates have been in line with the submission deadlines and the main changes are around primary care co-commissioning. Barts Heart centre event 5 February 2015 Invitation to visit has been circulated to wider membership, it will be re-sent to all clinical leads. Henry and Archna will be attending. Primary care committee In setting up this committee, representatives are needed from the Health and Wellbeing Board, Health Watch, Public Health and the council. As this will be a senior level meeting, Robert McCulloch-Graham and Councillor Assad to be invited.

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Shadow People’s Panel The panel will provide advice around governance, communications as well as how to involve and engage patients. 30 patient leaders will be in place by October 2015. The specification around the facilitation will be ready by end of March 2015. The team is looking into potentially recruiting another 1 or 2 Lay members for the primary care work. Public Health update Health Watch: The current arrangement is a 4 year contract with a 2 year break, which is due in April 2015. CCG’s position needed on whether it is worth going out to tender or re-specification by addressing existing issues and getting a better specification in place. Commissioners in the council: The corporate management team at the council have been asked to perform a ‘best value review’. Based on the outcome of the review, the commissioners will make a decision on whether more power needs to be exercised. The executive committee will be kept informed of any developments. London Transformational Programme This is a joint London wide initiative around mental health and primary care. Sam to provide an overview at a future OD session. Digital Mental Health The London Health Commission is developing a London wide online portal for mental health services and is seeking an organisation to take responsibility. This follows the launch of In The Know, which is a directory for mental health services in Tower Hamlets.

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Equality and Diversity Committee


4.6 Equality and Diversity Committee Haroon Rashid – Governing Body member

Shuma Begum – Business Manager

V


This report updates the Governing Body on the meeting of the Equality and Diversity meeting on the 13 January 2015.

Review of Equality and Diversity strategies, policies and procedures

The committee agreed to meet three times a year with adhoc meeting’s in between with the key members.

The committee agreed that the Equality and Diversity Strategy will go to SMT in May 2015 and then to the June 2015 OD session with a view to sign off at the July 2015 Governing Body.

Additional Support

The committee decided that the CCG would require additional support to deliver its Equality and Diversity agenda and agreed to draft a specification for additional support in the next two weeks which will be reviewed by the Chair of this committee at the beginning of February 2015.

Staff Checklist

The committee agreed to undertake a staff checklist for this year.

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Governing Body Meeting - Part I Agenda

Documents

Transcript of Governing Body Meeting - Part I Agenda