NHS City and Hackney Clinical Commissioning Group (CCG) Board. Friday 25 April 2014,

Transcription

1 NHS City and Hackney Clinical Commissioning Group (CCG) Board Friday 25 April 2014, Room TBC, Tomlinson Centre, Queensbridge Road, London, E8 3ND AGENDA Chair: Dr Haren Patel Agenda Items 1. Welcome, introductions and declarations of Interests Led by & Appendix number Haren Patel Verbal Timing (5 mins) 2. CCG Committee business: a. Minutes of the last meeting; b. Register of Interests; c. Matters arising. Haren Patel Papers 2a & 2b Pages (5 mins) 3. Questions from the public Haren Patel Verbal (10 mins) CLINICAL STRATEGY (FOR DECISION) 4. Strategic Plan for North East London Haren Patel Paper 4a & 4b (15 mins) Pages Cancer and Cardiac changes update Haren Patel Papers to follow (15 mins) Pages TBC 6. CCG-HUHFT Board to Board reflections and next steps Haren Patel Verbal (15 mins) 7. CCG Contracts with GP Providers Jaime Bishop Papers 7a & 7b (15 mins) Pages Chair: Dr Clare Highton Chief Officer: Paul Haigh

2 PERFORMANCE 8. CCG Finance update: Month 12 Finance and Activity report; Contract updates; 2014/15 financial plan. Philippa Lowe Papers 8a & 8b Pages (10 mins) 9. Year end reporting Philippa Lowe Paper (15 mins) Pages FOR INFORMATION 10. Reports from Subcommittees of the Board: a. Key issues from the March 2014 Safeguarding Group; b. Key issues from the April 2014 Clinical Executive Committee; c. Key issues from the April 2014 Audit Committee. Haren Patel Papers 10a, 10b & 10c Pages (5 mins) 11. Friday 30 May 2014 draft CCG Board agenda Haren Patel Paper 11 Pages (5 mins) 12. Any Other Business Haren Patel Verbal (5 mins) 2 Chair: Dr Clare Highton Chief Officer: Paul Haigh

3 MINUTES OF THE NHS CITY AND HACKNEY COMMISSIONING GROUP BOARD HELD ON FRIDAY 28 MARCH 2014 AT BLOOM 1, TOMLINSON CENTRE, QUEENSBRIDGE ROAD, LONDON, E8 3ND PRESENT: Dr Clare Highton (CCG Chair) Dr Haren Patel (CCG Clinical Vice Chair) Dr Gary Marlowe (CCG Board GP) Mariette Davis (CCG Lay Member for Governance) Jaime Bishop (CCG Lay Member for Public and Patient Involvement) Honor Rhodes (CCG Associate Lay Member) Siobhan Clarke (CCG Board Nurse) Christine Blanshard (CCG Board Consultant) Paul Haigh (CCG Chief Officer) Philippa Lowe (CCG Chief Financial Officer) IN ATTENDANCE: Emma Craig (Hackney HealthWatch) Sam Mauger (City of London HealthWatch) Dr Penny Bevan (LBH Director of Public Health) Matthew Knell (CCG Business Co-ordinator) Mark Scott ( APOLOGIES: Lee Eborall (CSU Deputy Director of Contracts) Agenda Item 1 Welcome, introductions and declarations of Interests The CCG Chair, Dr Clare Highton (CH) welcomed members to the March 2014 meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Board. Agenda Item 2 CCG Committee business Minutes of the last meeting Mariette Davis (MD) requested that the line MD did confirm that the Committee was assured that the Contracts were free from conflicts of interest, but that the Committee was not in the business of vouching for value for money, it did not possess the knowledge or responsibility to examine this area. be removed from the minutes of the February 2014 CCG Board minutes as an inaccurate statement. The Board agreed the change and accepted the rest of the minutes as a true statement of the meeting. Register of Interests 3 Chair: Dr Clare Highton Chief Officer: Paul Haigh

4 The GPs present at the meeting, CH, Haren Patel and Gary Marlowe all recorded interests in agenda item 10, 2013/14 Payments to GP practices as providers and the register of interests was noted. Matters arising Sam Mauger (SM) asked the Board if the CCG was keeping an eye on developments with regards to the national prescribing changes discussed at the previous months meeting. CH confirmed that the CCG is monitoring national policy and emphasised that it doesn t appear as though national policy has changed and that the centrally developed policy has always been based on the concept of quality adjusted life year (QALY). The wording of the consultation document is unclear, but it doesn t appear to be suggesting a change from the QALY system to one based on patient economic value. Honor Rhodes (HR) added that the local Independent Funding Review Panel (IFR) does not consider patient age and indeed is not supplied the information unless it relates specifically to the clinical case before the panel. SM asked whether the CCG will be confirming this approach publically and CH responded that it would be included in the CCGs forthcoming strategy publication. Agenda Item 3 Questions from the public No members of the public posed questions to the CCG Board. Agenda Item 4 Cancer and cardiac changes Paul Haigh (PH) updated the Board that NHS England (NHSE) had not yet published the business case covering proposals for changing cancer and cardiac services in London. The document will be distributed to the Board when received. PH moved on to inform the Board that the circulated papers outlined a breakdown of the CCG s role in the cancer and cardiac area and that recent discussions with NHSE has resulted in CCGs taking on a formal decision making role in the changes. CCGs will form a sub committee to examine, discuss and make a recommendation to NHSE on the changes, with City and Hackney needing to select management, clinical and lay member representatives to the body. PH confirmed that the meeting will meet in public, and that all NHSE decision making bodies in this area will meet in public, with advertised dates, times and venues. PH confirmed that the sub committee can seek assurances from Barts Health before reaching any conclusion. PH added that discussions are underway amongst local CCGs for City and Hackney to take the lead on behalf of other CCGs in monitoring and assuring Barts Health through the change process. SM asked if NHSE is looking at a plan B, should CCGs not be assured that the proposed changes are in the patients best interests. CH replied that any decision will be a majority decision and that City and Hackney is the only CCG to have taken an opposing line to the proposals. CH added that this position will be used to try and make the decision and 4 Chair: Dr Clare Highton Chief Officer: Paul Haigh

5 changes as robust, clinically safe and with good key performance indicators (KPIs) to ensure the service performs well. Christine Blanshard (CB) flagged that other CCGs had also raised concerns regarding the cancer service changes and CH responded that this was the case, but that these changes were largely to specialised services, where CCGs did not have as much of a role, although CCG pathways and travel arrangements for patients would be affected. CH added that large numbers of patients also travelled in to London from the surrounding counties and that the changes would probably mean this activity slows as they are diverted to services out of London. Jaime Bishop (JB) stated that the process had been really lacking in patient involvement or consultation so far and the documentation seen so far outlined that NHSE believed that no patient consultation was needed, which JB found troubling. JB asked how the process can be made more transparent and constructive. PH repeated that the NHSE public meetings will be publicised, and JB continued that only London Borough of Hackney (LBH) had been consulted, no other patients or patient groups had been approached. Siobhan Clarke (SC) asked whether the clinical case for change was strong enough, as it appeared to be a largely financial driven change proposal. CH replied that it was true that the Heart Hospital was a relatively small clinical unit with rising waiting lists, however Barts Health are also troubled and need income and organisational support to make the services a success. Consultants treating more patients, on a more regular basis is a clear clinical win. GM asked why the cancer and cardiac changes had been conflated, as the two being intertwined was not helping with assessing the changes. GM stated that the cancer changes had more support in the clinical community, but the cardiac changes were much more controversial. Mark Scott (MS) replied that the previous NHSE position was that as much tertiary provision of these services should be compiled as possible, but North East London only has the Heart Hospital. The old clinical network system used to help in gathering views and input to these change processes, but due to NHS changes is no longer in operation. Cynthia White (CW) asked the CCG to ensure that the business case for change is closely examined when released. CH confirmed that this would happen. CB asked if the changes would affect Homerton University Hospital NHS Foundation Trust (HUHFT), who had historically referred onwards to either University College London Hospital (UCL) or Barts Health as clinically appropriate, depending on which Trust was providing the most accessible service. This had meant that HUHFT was able to lever higher clinical quality by referring sensibly, something that the changes would put an end to. CH remarked that while this was true, HUHFT has been making closer links with the Brompton Hospital. JB asked if the business case was an equivalent of a buoyancy aid for Barts Health, considering their financial troubles, the extra activity the changes would generate for them 5 Chair: Dr Clare Highton Chief Officer: Paul Haigh

6 and the potential for international research and patients the changes would open up. Penny Bevan (PB) added that although this may be the case to an extent, the Brompton Hospital is so established internationally, that it would be very hard to challenge its position. Mariette Davis (MD) remarked that it certainly appeared to be a primarily financially driven case for change, with everything else taking second place. The Board nominated PH, CB and MD as CCG representatives to the decision making NHSE sub committee. DECISION: PH, CB and MD nominated as CCG representatives to the decision making NHSE sub committee. Agenda Item 5 Better Care Fund MS summarised the paper circulated to the Board, detailing that the Better Care Fund (BCF) proposals concentrated on patients with multiple long term conditions (LTCs) and mental health issues in the elderly. The proposals include 6 key performance targets that will be monitored and managed. MS continued to explain the sign off process, which needed to involve the Local Authorities, CCG and the Health and Wellbeing Boards (HWBs). The sign off process was not yet complete and needed to take account of slightly differing approaches to the Fund, for instance the City of London (CoL) commission s services for its resident population, while the CCG is funded for the smaller registered population. The Health and Wellbeing Boards will be discussing and agreeing the proposals at their meetings on 1 April CB asked whether achievement of the Funds aim was for the CCG and partners to save money, or is the proposal an investment? CH confirmed that no money would be saved through the scheme and GM added that the way the CCG has approached the Fund is to ensure an improvement in care. The way the Fund had been designed centrally did not lend it to achieving NHS savings. PL confirmed that the CCG has not planned on any savings through the use of the Fund as the CCG was performing well already on most of the metrics; the CCG was fortunate in not having to rely on savings from the Fund, but could reinvest any released. SC asked whether the national rollout of the BCF initiative was leaning towards the creation of another industry, although the intentions behind it seemed good. The targets agreed across partner organisation appeared realistic, but would they stretch local services to a constructive level? MS responded that City and Hackney was in a position where the area was performing well against the measures included in the BCF nationally, so extra performance increases would be challenging to achieve. The small elderly population locally meant the local profile was different to the norm which didn t help with this either. SC asked if the CCG has looked at tying the BCF initiative into wider integrated plans locally, to avoid any risks of the BCF being developed and managed in a bunker. MS confirmed that the start-up group, of colleagues from across local organisations will be a 6 Chair: Dr Clare Highton Chief Officer: Paul Haigh

7 short to medium term body and that in the long term, the Fund will be managed by the CCG in the relevant clinical Programme Board. PH informed the Board that NHSE had questioned whether a separate CoL BCF was needed, but that the CoL and CCG had successfully defended this so the Funds retain consistency across local authorities. SC asked whether there was a capital spend component to the Fund and PL confirmed that there was very little capital funding available to the NHS, particularly to CCGs for investment. PL stated that while the proposal before the Board was the current best guess, some elements of the plan may need to change over time to adapt to local circumstances, for example if some planned investments didn t deliver the expected outcomes in 2014/15. The CCG s plan is for the NHS to hold overall ownership of the Fund, but again, this may change in the future and that there may be advantages to ownership transferring to local authorities due to differences in the processing of value added tax (VAT) and other procedures. SM asked how the CCG intended to monitor improvements in patient care and experience. CH responded that the CCG would be using clinical audit and patient feedback as part of its performance monitoring framework, but a baseline position needed to be set to ensure consistent measurement over time is possible. MD asked where care plans will be drawn up in the new system and CH replied that GPs will be responsible for the production of the plans. CH stated that the Board would receive regular updates on the implementation and performance of the plan. Agenda Item 6 CCG Finance update PL presented the latest CCG finance report to the Board, noting that the CCG has now agreed the 2013/14 contract with HUHFT and consequently has paid all valid invoices to the Trust. PL also briefed the Board that the CCG has been instructed by NHSE that the CCG can only hold 250k cash at year end, this late development means that the CCG has settled a number of current year disputes, but is reliant on the Commissioning Support Unit (CSU) and Shared Business Support (SBS) teams to rapidly action payments. PL stated that the CCG finance team is focused on year end processes and drawing up comprehensive financial plans for 2014/15 currently. The projected year end position is indicating a 27m surplus, although there are areas still under further investigation, including Barts Health activity data, NHS Property Services requests for funding and prescribing charging disputes with the local authorities. MD asked whether PL expected any further year end surprises and PL responded that all known risks are outlined in the Board paper, but that she couldn t promise that the CCG wouldn t be surprised by either a national announcement or late invoicing for noncontracted activity on the 31 st of March. 7 Chair: Dr Clare Highton Chief Officer: Paul Haigh

8 CH thanked PL for the diligent work safeguarding the City and Hackney budgets, noting that while the surplus is large, it has been challenging to secure the correct funds from across the system. CW asked whether the quality of data issues at Barts Health would affect the proposed cancer and cardiac changes. PL responded that this risk will is a specialised services one for cancer and cardiac. The CSU is good at detecting issues in this area, but that the challenge process to ensure correct payments are made did need further work and she wanted Internal Audit to look at this in 2014/15. PL briefed the Board that 2014/15 contract discussions have commenced with HUHFT with an initial offer and that a HUHFT response was expected that day. Discussions over the community health services (CHS) component of the contract were expected to be complicated and the CCG is investigating the costs of similar services across London to ensure value for money is attained. PL confirmed that City and Hackney is not involved directly with the Barts Health negotiations, but understands that discussions are progressing. Whittington Health is seeking a block contract agreement as they are having problems with a new data system, although negotiation will be needed on the level and detail of any contract. MD asked if there was any estimate on when contracts will be agreed and signed and PL responded that the aim is to conclude these quickly, but while discussions have started positively, no definitive timetable had been agreed yet with Foundation Trusts. SC asked how Commissioning for Quality and Innovation (CQUIN) measures are being developed this year and CH updated the Board that the CCG is linking with Public Health on the appropriate measures, for instance smoking. The CCG has discussed and agreed its ambitions and is working up the detail to feed into the negotiation process. SM asked why acute and CHS care are separated at HUHFT, when the direction of movement is towards integrated care. CH responded that while it would be ideal to merge the two services, the CCG needs to work in the current reality and more work was needed. PL replied that it is two schedules within one contract. HR asked whether the CCG has analysed its risk analysis from the start of 2013/14 to see how it performed against the actual year end position. PL confirmed such as exercise would be conducted and used to help inform future planning. The plan submitted to the Board at the start of the year was broadly accurate, and the surplus was created by late return of a specialised services topslice, the return of the PCT surplus and deferred expenditure on non-recurrent projects. NHSE have confirmed that they will honour the CCGs return of surplus, but couldn t give a cash amount to support it. However, the CCG should manage to meet its planned commitments. Any underspend against those commitments may be forfeit in future. PL stated that the CCG is planning to roll a buffer of 27m forward, year on year, live within its means and only use the surplus monies if ultimately needed. The forward financial plan allows for reasonable Quality, Innovation, Productivity and Prevention (QIPP) targets and investment allowances. CH commented that if the CCG didn t have the cash, the roll forward surplus was a paper surplus. 8 Chair: Dr Clare Highton Chief Officer: Paul Haigh

9 CH asked if the CCG will be asked to loan monies to other CCGs. PL replied that it is now unlikely that direct loans will be requested, however NHSE have indicated many times they would like to move money around. The CCG plan does have a risk share contribution to WELC. HR asked how neighbouring CCGs were performing and PL updated that Newham and Tower Hamlets both appeared to be in healthy positions, while Waltham Forest may experience issues. SC asked how the performance of the CCGs investments into services will be tracked and when they will be reported on to the Board. PL confirmed that they will be covered in reports to the Finance & Performance Committee. Agenda Item 7 Board to Board meeting with Homerton University Hospital NHS Foundation Trust The Board discussed the upcoming Board to Board event with HUHFT and HR noted that she and JB had recently met with Tim Melville-Ross, the Chair of HUHFT for a productive conversation that touched on how to make the contracting process smoother, amongst other areas. JB added that the HUHFT contract had just been signed at the time of the meeting, which helped and that the conversation had provided a good starting point for the Board to Board to continue. MD asked whether a medium to long term system of buddying up with counterparts on the HUHFT Board would be helpful to support closer working. Emma Craig (EC) noted that Hackney HealthWatch would receive the HUHFT response to their recent report in April SM added that the HUHFT Board appears to be somewhat in flux currently, with several positions either open for recruitment or opening up shortly. Agenda Item 8 Social Prescribing Project update This agenda item was deferred to a future meeting. Agenda Item 9 PPI Committee update JB briefed the Board on recent developments in the CCG s public and patient involvement (PPI) work, including that a support process for practices wishing to engage in the super practice public groups (PPGs) is now in place, although he noted that the CSU support hasn t been forthcoming, potentially due to the staff changes between the CSU and CCG. The PPI Committee now includes representatives of all CCG Consortia and has recently been working through how to launch and use the innovation fund that the Board requested be set up. CW asked whether the CCG s work in this area will progress into more definitive pieces of work, as much has been on the setting up of structures and meetings to date. It would be 9 Chair: Dr Clare Highton Chief Officer: Paul Haigh

10 useful to produce clear, definite and practical pieces of work in the future. SM commented that the Committee she attended was an excellent meeting and that she hoped the closer working across PPGs might enable more engagement with younger residents and patients. JB endorsed this and noted that the CCG is talking with the Hackney Youth Parliament to look at how they might be involved with the local NHS. Agenda Item /14 Payments to GP practices as providers CH, HP and GM recorded their interests in this item and took no part in the Board decision. PL outlined the process followed by the CCG, detailed in the circulated paper and confirmed that the payments to GP practices had been assured by the Audit Committee. The Board confirmed that they are content for the payments to GP practices to proceed as outlined in the papers. DECISION: Payment to GP practices for services rendered to the CCG to proceed as detailed in Board papers. Agenda Item 11 Reports from Subcommittees of the Board The Board accepted the reports from its sub-committees and noted the contents. Agenda Item 12 Friday 25 April 2014 draft CCG Board agenda The Board noted the agenda of the following months meeting. Agenda Item 13 Any Other Business MD asked whether all CCG Committees could report to the CCG Board on a regular basis. CH responded that summary notes are included in Board papers and that the PPI Committee could be added to this process. PL informed the Board that the CCG will be moving to its new premises in the main St Leonard s Hospital block from the 1 st of April 2014 and will be joined by the CSU staff transferring to the CCG. 10 Chair: Dr Clare Highton Chief Officer: Paul Haigh

11 AGREED BY: AGREED ON: 11 Chair: Dr Clare Highton Chief Officer: Paul Haigh

12 NHS City and Hackney Clinical Commissioning Group Register of Interests Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Christine Blanshard 28/09/2012 CCG Board Consultant Salisbury Hospital NHS Foundation Trust Medical Director at Salisbury Hospital NHS Foundation Trust that does not hold any contracts with the CCG. Clare Highton 18/04/2013 CCG Chair Long Term Conditions Programme Board Clinical Lead GP / Chair Childrens Programme Board Lead GP Clare Highton 18/04/2013 CCG Chair Long Term Conditions Programme Board Clinical Lead GP / Chair Childrens Programme Board Lead GP Lower Clapton Group Practice (CCG Member Practice) Tavistock and Portman NHS Trust Principal Partner at Lower Clapton Group Practice, our practice now provides a CCG Commissioned community ENT clinic run by my GP partner Dominic Roberts with our local ENT consultant. The practice also employs 3 Heart Failure nurses and their HCA. Lower Clapton is a research associate practice, so does not hold grants but does participate in research that is funded. Rob Senior, the Medical Director at the Tavistock and Portman NHS Trust is my husband. Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative Urban Inclusion Community Director of Urban Inclusion Community Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative Healthwatch Tower Hamlets Chief Operating Officer of Healthwatch Tower Hamlets Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative ELFT Tower Hamlets CCG Undertaken research for ELFT, Tower Hamlets CCG, Hackney and the City PCT. Hackney and the City PCT Emma Craig 27/02/2014 London Borough of Hackney Healthwatch Chair Women and Health Counselling Co-ordinator at this Camden based charity Gary Marlowe 16/04/2013 CCG Board GP Planned Care Programme Board Clinical Lead GP / Chair De Beauvoir Surgery (CCG Member Practice) Partner at De Beauvoir Surgery of GMS services and a provider of Locally Enhanced Services. Gary Marlowe 16/04/2013 CCG Board GP Planned Care Programme Board Clinical Lead GP / Chair Gary Marlowe 16/04/2013 CCG Board GP Planned Care Programme Board Clinical Lead GP / Chair Gary Marlowe 18/10/2013 CCG Board GP Planned Care Programme Board Clinical Lead GP / Chair London-wide Medical Committee British Medical Association Homerton University Hospital NHS Foundation Trust City and Hackney Representative at the Londonwide Medical Committee, the representative body for London s GPs. London Regional Council Representative for the British Medical Association (the major trades union for medical practitioners) - regional representative, representing doctors professional and working interests. CCG appointed Governor to HUHFT, the main provider of services to the CCG. 12

13 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Haren Patel 14/11/2013 CCG Clinical Vice Chair Clinical Executive Committee Chair Prescribing Programme Board Clinical Lead GP / Chair Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Honor Rhodes 16/04/2013 CCG Board Associate Lay Member Individual Funding Request Panel member Latimer PMS Plus Practice (CCG Member Practice) Latimer PMS Plus Practice (CCG Member Practice) North East London Medicine Management Committee City and Hackney Local Medical Committee Acorn Lodge Nursing Home High Street pharmacy in Brent. Barton House Practice (CCG Member Practice) Tavistock Centre for Couple Relationships Children and Family Courts Advisory and Support Service (CAFCASS) Early Intervention Foundation The Institute of Wellbeing Oxleas CAMHS Senior Clinician and Management Lead for Project and Intermediate/Secondary Mental Health Service Provision. Interest in mental health services at the Latimer PMS Plus Practice. Partner, Dr Geeta Patel clinician with special interest. Co-Chair of North East London Medicine Management Committee Member of the City and Hackney Local Medical Committee (the representative body for GPs) Lead Clinician providing NHS GMS and Enhanced Services under Nursing Home LES to the Acorn Lodge Nursing Home. Interest in intermediate care and community services under PMS contract. Business interest in high street pharmacy in Brent. One of the Directors (from AUGUST 2013) and shareholding greater than 5%. Patient at Barton House, Albion Rd Practice Director of Strategy at the Tavistock Centre for Couple Relationships. Non Executive Director at Children and Family Courts Advisory and Support Service (CAFCASS). Trustee at the Early Intervention Foundation. Mentor to CEO of The Institute of Wellbeing, a voluntary agency who may seek to contract with the NHS in future in South London. Partner is a Consultant Family Therapist with Oxleas CAMHS 13

14 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Jaime Bishop 23/09/2013 CCG Board Public and Patient Involvement Lay Member Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 CCG Board Public and Patient Involvement Lay Member Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 CCG Board Public and Patient Involvement Lay Member Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 CCG Board Public and Patient Involvement Lay Member Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 CCG Board Public and Patient Involvement Lay Member Public and Patient Involvement Committee Chair Fleet Architects LTD HealthPorts LTD Architects for Health Barretts Grove Practice ELIC (East London Integrated Care) LTD Director of Fleet Architects LTD, a company working on socially valuable buildings. We do not currently have any involvement in the City and Hackney area. 50% shareholder in Fleet Architects. Fleet have been appointed in 2013 to advise on the reconfiguring of property in Newham (The Centre Manor Park) which involves liaising with tenants including the CHS arm of the East Foundation Trust (ELFT). Fleet Architects own 33% of HealthPorts LTD, a (as yet not trading at all) company established to design accessible sustainable modern health centres. Fleet provide design services. There are currently no projects although in the course of researching new projects HealthPorts has contact both with the NHS, GPs and other health providers outside of the City and Hackney Area. Executive Committee Member and Head of Education at Architects for Health, I run annual Student Design Competitions in conjunction with other healthcare stakeholders including NHS Trusts and 2012 were in conjunction with Guys and St Thomas NHS FT. Patient as a Hackney General Practice, Barretts Grove. Member of the ELIC (East London Integrated Care) LTD (a Practice Based Commissioning body) Audit Committee that is overseeing the wind up of the dormant social enterprise. Karl Thompson Not yet received CCG Urgent Care Programme Director and Head of Corporate Affairs Not yet received Lynn Strother 18/04/2013 City of London HealthWatch representative Age UK London The Greater London Forum for Older People ELIC is now defunct save some final legal winding up proceedings underway. Not yet received The charities I am employed by Age UK London and The Greater London Forum for Older People are funded by grants and donations. 14

15 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Mariette Davis 16/04/2013 CCG Board Governance Lay Member Audit Committee Chair Remuneration Committee Chair Mariette Davis 16/04/2013 CCG Board Governance Lay Member Audit Committee Chair Remuneration Committee Chair Mariette Davis 16/04/2013 CCG Board Governance Lay Member Audit Committee Chair Remuneration Committee Chair Acanthus Advisers Private Equity Limited Aletheia Partners LLP Tower Hamlets CCG Acanthus Advisers Private Equity Limited, a placement agency not operating in or with the NHS. Aletheia Partners LLP, a Private Equity advisory firm not operating in or with the NHS. Lay Member for Governance for Tower Hamlets CCG Paul Haigh 16/04/2013 CCG Chief Officer ELIC (East London Integrated Care) Chief Executive of ELIC (East London Integrated Care) (a Practice Based Commissioning body registered as a social enterprise). The social enterprise has now ceased trading and is being wound up Also member of ELIC s Audit Committee that is overseeing the wind up of the dormant social enterprise. Paul Haigh 16/04/2013 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR and Organisational Development (London), NHS England. Philippa Lowe 16/04/2013 CCG Chief Financial Officer GreenSquare Group Group Audit Committee Chair and Group Development Committee member for GreenSquare Group, a Group of Housing Associations. KPMG are internal audit provider to the HA and external auditors to the CCG. GSG hold many contracts with public and private sector bodies. Philippa Lowe 16/04/2013 CCG Chief Financial Officer PIQAS Ltd Director of PIQAS Ltd, a Consultancy firm. Dormant company from 1/4/13. Sam Mauger 01/04/2014 City of London HealthWatch representative Age UK London Chief Executive Officer of Age UK London, a regional charity working closely with local Age UKs and Age Concerns in each of the London boroughs and the national organisation Age UK. Sam Mauger 01/04/2014 City of London HealthWatch representative Age Concern London, Age Concern London Trading Limited, Age Concern London Retail Limited Company Secretary of Age Concern London, Age Concern London Trading Limited, Age Concern London Retail Limited Sam Mauger 01/04/2014 City of London HealthWatch representative Age Concern City of London Company Secretary of Age Concern City of London 15

16 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Sam Mauger 01/04/2014 City of London HealthWatch representative Age England Association (Company Limited by Guarantee) Director of Age England Association Sam Mauger 01/04/2014 City of London HealthWatch representative LASA Trustee of LASA, a a social welfare law and tech charity. Sam Mauger 01/04/2014 City of London HealthWatch representative Westminster Arts Trustee of Westminster Arts, a community-based charity that is established to promote social inclusion through the development and delivery of innovative arts based activities and experiences. Siobhan Clarke 22/02/2013 CCG Board Registered Nurse YOUR HEALTHCARE CIC MANAGING DIRECTOR OF YOUR HEALTHCARE CIC WHICH HOLDS CONTRACTS FOR HEALTH AND SOCIAL CARE IN KINGSTON AND RICHMOND. ALSO SHAREHOLDER. Siobhan Clarke 12/09/2013 CCG Board Registered Nurse Albion Care Alliance CiC Director and shareholder of Albion Care Alliance CiC, an alliance of a number of mutual or co-owned organisations that aim to grow businesses and services that add value to member organisations, their services, staff and society. 16

17 WORKING DRAFT Last Modified 09/04/ :08 GMT Standard Time Printed 07/04/ :06 GMT Standard Time NE London Intensive planning support: Notes from the Mobilisation meeting 8 th April

18 About this document This document is a playback of the key discussions in the Mobilisation meeting for the NE London dedicated planning support project held at Southside on the 8 th of April. It will be used to guide the focus of the McKinsey work over the next 4 weeks, inform the refresh of our delivery plan Form the basis of key design principles and ways of working we will be adopting going forward 18

19 Why are we here and while individual LHE partners are creating 5 year plans, no coherent system wide plan exists NE London is facing a number of challenges One of 11 local health economies nationally identified as particularly challenged and needing intensive planning support The local health economy challenges and pressures are well understood and documented in the SPG packs made available to all in December By 30 th June all LHE partners have to submit 5 year strategic plans to various national bodies for assurance CCGs to submit plans to NHS England Barts & BHRUT to submit plans to NHS TDA Homerton, ELFT and NELFT to submit plans to Monitor The national tripartite (NHSE, TDA and Monitor) would like to ensure that all plans submitted together Sustainably address both the clinical and financial challenges within the local health economy to ensure better care for the patients are consistent and based on coherent, common assumptions across commissioners and providers for patient flows, care delivery models and service configurations Clearly bring out the interdependencies between the different plans Present clear evidence in support of proposed change

20 Why North East London was perceived to be a challenged health economy? NOT EXHAUSTIVE Challenges faced by the local health economy to build sustainable plans Financial challenges Quality challenges Geographic/ historical challenges Forecast aggregate funding gap of ~ 200m across the patch by FY18/19 after tariff efficiencies Both large acute trusts are operating with deficits. Forecast outturn FY14/15: Barts m deficit BHRUT m deficit All providers are facing YoY cost challenge of 5% Two of the three acute providers are non-fts Uncertainty over the impact of the mental health tariff and budget squeezes BHRUT placed in special measures by the TDA in 2013 Parts of North East London have the highest levels of deprivation and birth rates in the country Existing strategies may not be sufficient to answer the forecast challenges, and have been implemented at varying pace and levels of support Limited collaboration across the seven commissioners Inadequate governance structure across the geography to develop a coherent strategy Existing challenges, increasing over time Lack of consensus across organisations on how to proceed On downward trajectory, but not yet failing, and not insoluble, so support can make a difference SOURCE: Monitor Addendum: Invitation to tender for intensive planning support to challenged local health economies, (Ref: T-POL ) Feb 2014; LHE meeting 3 rd April 2014

21 Hopes Brings alignment and coherence across NEL Clarity of problem and scope Includes all settings Brings alignment and coherence Implementation focussed and radical 21 Aligns commissioners and providers and their plans Create one single set of truth Strong alignment with existing work in INEL Creates coherence for everybody Helps push for clarity in BHRUT clinical strategy align with wider NEL strategy Clear on problem trying to solve and being realistic Clear about problem trying to solve Helps address challenges that made earlier plans difficult to implement Is regarded as money well spent at the end of the support period added value (coherence) Helps articulate the change needed and what resources / investment is needed to support it Also focuses on prevention agenda Ensure Mental Health gets equal profile with Acute Helps accelerate pace of improvement in Primary care, Out of hospital and in Hospital (including social care and specialised commissioning) Build (and share) on work done so far Work fits in bigger context Opportunity to work jointly and be ambitious Builds on clinical solutions/clinical focus Builds on local plans in place brings together system leadership (including LA) Plays to strengths of organisations Help move plans to implementation 5 year plan is that something can be used from Day 1 Get to grips with big issues (and don t shy away from key challenges e.g., estates) Sufficient sense of crisis to emerge that allows us to embrace radical change e.g., changes to incentives and commissioning etc.

22 Fears Duplicates work Produces a sub optimal plan Produces a plan that is deliverable Produces a plan that is not locally owned Replicate existing work Fail to build on and combine the work that we already have to create a joint plan Fail to make plans real for patients, public and workforce Fail to tackle difficult issues e.g. estate use Not be radical enough Produce a plan that is divorced from and fails to tackle the main drivers of current challenges e.g. workforce strategy Loose focus on key elements critical for delivery Not acknowledge the true timescale it will take to get things right Produce a plan but not use it as overall plan as a real template for delivery Fail to align across the delivery system and any plan will disintegrate Fail to produce an implementable plan difficult to move the tanker Large acute trusts struggle to be flexible enough to make the necessary changes Simply produce another set of different numbers Force a solution not supported by the figures Focus on North East London and lose sight of North Central London Distract ourselves from delivering our good local plans and fail to drive real value during the 11 weeks Produce a McKinsey / Southside view of the local health economy that is not owned locally Water down our ambition and derail our current aspirations 22

23 Proposed principles and implications for ways of working Principles Anchor all plans in what they mean for patients Take a whole economy view Co-create solutions with local stakeholders Underpin clinical strategies with robust clinical evidence Build on existing work but also challenge assumptions Keep innovation and new models of care in mind Out of hospital care is as important to the solution as acute care Implications for ways of working Keep impact on quality of care at centre of all planning Involve patient reps in local clinical groups Providers and commissioners take joint accountability and consider efficiency for all not just few Share numbers and information transparently Create something practical and implementable Engage with all stakeholders Work with existing clinical and finance groups Be clinician led in thinking about care models options etc. Gather robust evidence e.g., for OOH interventions Be data driven and robust and don t shy from difficult choices (e.g., implications for estates, reconfig etc.) Be prepared to consider changes to commissioning incentives and payment models etc. Any solution to have equal emphasis on changes to within acute care and changes in other settings such as Primary care, Mental health, community etc. 23

24 Outcomes expected Outcomes expected Forecast: to create commissioner and provider baselines, summary and gaps Solution development: to create range of clinically informed options Plan development: to model impact of options to inform plans A consistent, integrated view of all three commissioning plans Population needs and common commissioning aspirations Refreshed financial baselines and projected forecasts Overlay of impact of existing commissioner plans Identification of finance and clinical gaps 2. A refreshed provider baseline and projected forecast positions based on current models of care and existing productivity plans, clearly identifying the financial and clinical / quality gaps 3. Clear articulation and agreement around the question(s) that need(s) to be addressed collectively across the local health economy, a supporting narrative and alignment within which the answers to that questions need to be formed 4. Range of clinically informed options (with evidence base) for reducing those gaps by changing models of care both in and out of hospital in order to meet the financial & clinical gaps and therefore build broad NEL wide alignment around a preferred consistent strategy for the area 5. High level assessment of those options (building on existing work: H4NEL, BCF, and WELC & BHR integrated care etc.) to inform implications for providers (in terms of in house changes, reconfiguration etc.) changes to plans / LTFMs etc. 6. A clear set of enablers and next steps for the system players and a forum that could continue beyond the project timelines supporting the on-going system evolution

25 Proposed approach Focus for next 4 weeks April May June Solution development: to create range of clinically informed options Forecast: to create commissioner and provider baselines, summary and gaps Plan development: to model impact of options to inform plans Activities Interview stakeholders to identify current challenges, initiatives and status of plans Review CCG CSP submissions and create integrated needs view Create refreshed CCG baseline and forecasts; overlay with existing plans to identify gaps and any inconsistencies Refresh provider baseline & forecasts Overlay provider efficiency plans and identify remaining structural gaps Facilitate agreement over diagnosis Work with clinical groups to identify long list of options Gather evidence and use clinical input to assess options and create a prioritised list of preferred options - taking into account any cross area dependencies Facilitate of agreement over prioritised options High level financial impact modelling of identified options Complete modelling of high level financial impact Facilitate understanding of finance and estates implications of identified menu of options Provide critical friend input into final plans and advice on its refinement (where relevant) Help create a clear list of next steps for organisations to take forward beyond the project timelines Inputs Draft SPG 5 year strategic plans and Finance submissions to NHSE Provider 2 year plans and any latest strategy and performance diagnostics 25 Clinical and Finance working groups Existing Integrated care work Clinical evidence Bespoke modelling work with input from clinical and finance groups Provider 5 year LTFMs and any latest strategy and performance diagnostics

26 Emerging framework of the problem we are trying to address and the risks of not doing so PRELIMINARY Why is there a problem? The Financial challenge The Quality Challenge Significant demographic change is expected in the next 10 years (16% growth in population etc.) Rising patient expectations and national and London clinical standards have a significant impact on viability of delivery of services What constraints must be satisfied by any solution? What needs to be different about the approach this time? 26 Any acceptable proposed solution must Take into account the workforce implications Build on the existing work and relationships Be deliverable Include both Hospital and Out of Hospital care Willingness of providers and commissioners to take joint responsibility of economy as a whole Willingness to consider radical solutions and not shy away from difficult questions Think through and develop actions on the key enablers e.g., for estates, Organisation and incentives

27 Common Challenges for commissioners and providers Need to tackle existing structural challenges but also lift our heads to address the future challenges resulting from our changing population needs Demand challenges: population growth, health demand, disease changes Supply challenges e.g. workforce availability (retirement, affordable housing, ) Changing clinical standards Need to take a whole economy and triangulate resources, challenges and plans across commissioners and providers and what is available in the system Need to work at a number of levels Continue to push good delivery plans at the Borough level Strengthen relationships at the health economy level Need to develop OOH delivery despite primary care, mental health and community health providers facing financial challenges Need to consider radical solutions e.g., in incentives and commissioning Need to recognise real barriers to implementation and have actions to address these e.g. Need to align incentives across the health economy Need to model new workforce needs together e.g. GPs, new types of healthcare workers, involvement of LETB etc. 27 Note: SPG & provider specific challenges and current plans that were discussed have been noted, and will be refined over

28 22 April 2014 To: CC: Trust CEOs, CCG Chairs and AOs of the NE London Sector Challenged Health Economy Members of the project team Dear Colleagues, Re: The NEL Challenged Health Economy (NEL CHE) Programme Following the meeting of the NE London Reference Group on Tuesday 8 April and the first meeting of the resulting Programme Steering Group last Wednesday (16 April), we felt it would be helpful to share with you some key messages and some actions that we need you to take to ensure we can mobilise the work quickly and drive the maximum value from the support provided. This letter sets out the arrangements that were agreed to be put in place to ensure there is strong engagement in developing the aligned vision and 5 year strategic plans for future services in the North East London region, and to ensure that these build off of your existing plans. This is the first of a series of letters that will be issued by the programme to provide a regular update on progress. 1.0 Alignment with and building on other local system change The 7 CCGs are already working together in 3 Strategic Planning Groups (SPG): City and Hackney, WEL and BHR. This work is intended to complement and build on these current regional transformation programmes including, for example, the WEL Transforming Services, Changing Lives (TSCL), the OneHackney programme, and the BHR Integrated Care Coalition (ICC) which are already exploring options for provider sustainability and to respond to the intentions of commissioners. The programme will also review the impact of future changes to Specialised Services Commissioning and any other provider initiatives. The CHE Programme will therefore build on the significant work that has been undertaken to date by the existing local transformation and/or SPG programmes, and will work with them to share and review the most likely scenarios which result from this work so that these can be used to inform and align with future plans. The CHE programme will ensure that it builds on the overriding transformation principles shared by all commissioners and providers across North East London which are reflected in the development of the 5 year plans, such as those of new standards of acute care, development of integrated community services and transformation of primary care etc. The purpose of the CHE Programme therefore is to: Understand the size of the challenge and the potential sustainability across the local health economy by reviewing the current 5 year SPG and 2 year provider plans; Provide transparency on the interdependencies and linkages across plans; Work collaboratively with the local transformation programmes to consider possible options (e.g., alternative models for commissioning and providing care) where current proposed 28 1

29 plans are demonstrated to not achieve the required improvement in clinical outcomes and clinical and financial sustainability; Help feedback the implications of those alternate care models and identified interdependencies to enable the production of robust, aligned and deliverable strategic plans across the three SPG regions. The local transformation programmes continue to have responsibility for delivering the 5 year plans, and are meeting next week. Given the scope of the CHE work might differ from your existing local Transformation Programmes (and or existing SPGs), there may be a need to revise Terms of Reference and membership. In particular Local Authorities, patient groups and clinicians will need to engage in these groups (if not already doing so). If that is the case, please could you ensure the necessary changes are made. Specifically for this project duration the programme will coordinate two sets of commissioner and provider stakeholders one representing the WELC group, and the other representing the BHR group, represented by Jane Mehta and Jane Gateley respectively Action: Jane Gateley and Jane Mehta to link with providers and SPGs to propose amendments to Local Change Programme ToR and membership (if needed) in line with the need for the change programmes to act as the vehicles to do this work 2.0 Work Programme and timescales The programme will involve: Analysis and assessment of the baseline performance and financial viability of the CCGs and Trusts, including draft 2 year operational and 5 year strategic plan submissions. Review and analysis of the financial and clinical sustainability of the health economy in the light of local models developed as part of existing SPG Transformation Programmes. Where agreed by the Transformation Programmes, consider the development of alternative care models and service options to improve long term commissioning and provider viability. Evaluation of these options using an agreed set of evaluation criteria, and the development of a holistic health economy strategy that will consistently and coherently inform SPG and NHS England commissioning strategic plans across the region, which in turn will inform and support a sustainable provider market in-line with, NHS England s Call to Action, procurement law and the NHS Constitution. The programme of work to deliver this strategy has just commenced, and will run until the end of June supported by McKinsey. 3.0 Transparency As raised during the first Reference Group meeting and the first Steering Group meeting, given the pace and nature of the task the only way the work can be done it to have a principle of maximum transparency across CCGs and providers. In particular, CEOs are asked to approve by return, the transparent sharing across CCGs and providers of current plans and the financial modelling supporting them, recognising that data is still in draft form. Action: CEOs to confirm by return that 2 and 5 year strategic plans and supporting financial modelling can be shared across CCGs and providers, McKinsey and the tripartite bodies. 29 2

30 4.0 Governance Arrangements A governance slide for the NEL CHE work programme is shown in Appendix 1. NHS England, NHS TDA and Monitor are accountable for the process of developing a coherent plan to address the challenges of the local health economy. The Reference Group is accountable for developing the content of the work programme including the identification of options and recommending a preferred option. Local SPG Transformation Programmes are responsible for driving the work with support from McKinsey and the CSU. Local Organisations (CCGs, Trusts etc.) are accountable through their statutory governance arrangements for agreeing the final option and implementing the required changes. The operational delivery of the programme will be coordinated through a fortnightly Steering Group for which each SPG and provider has identified members. This group will manage the programme to ensure that there is sufficient drive from stakeholders. The group will serve as a resource for the NEL health economy and ensure the best value is driven from the programme. 5.0 Communications Effective communication will form a crucial part of the programme. There are a large number of stakeholders and associated staff that cut across and beyond both the Commissioner and Provider transformation programmes. All NEL CHE Communications will initially be aligned and managed through the Steering Group and disseminated through respective stakeholders and/or communication groups associated with existing transformation programmes. The Steering Group will monitor on-going levels of communication and determine if additional resources are required in the future. 6.0 Commitment to support the programme Clinical Commissioning Groups and Provider Trusts are requested to seek support through their respective governance arrangements to ensure timely support is provided to the work programme including the following: 1. Key senior stakeholders treat this work as a priority and are available upon request for key meetings. 2. Ensuring that McKinsey & Company acting as the Critical Friend will have reasonable access to data and key stakeholders in a timely fashion. 3. Agreement to the sharing of relevant and appropriate data, as required. 4. Stakeholder organisations will also identify key managers and care professionals to be engaged actively in the steering group and sub-groups. In particular early on engagement of Finance Directors will be critical to take decisions on the alignment of assumptions across the existing plans. CEOs are asked to stress the importance of the work to their Finance Directors. Action: CEOs to stress importance of participation to the Finance Directors and ensure their availability for this programme. Specifically over the next 2 weeks of April the programme would require the presence of your FDs and senior executive team in 2 key sessions (being setup). One of these will be a joint session with the FDs of the organisations in your local transformation groups to validate the alignment and gap analyses of your submitted plans so far, and the other will need to be a wider session of your full local transformation group itself for the project team to be able to playback their diagnostic and forecast findings to you, and for you to be able to identify the areas of further focus relevant for your local health economy. 30 3

31 The next meeting of the wider NE London CHE Reference Group is on 16 May and invites will be sent out shortly. An update and further communication slides will be issued after this meeting. 7.0 National expectations of commitment The national resources that have been applied to support this work locally set out an expectation on local health economies for engagement and commitment in the programme of work. Whilst I recognise that your commitment is already implicit in our joint work together, I thought it would be useful to be clear about the commitment expected from each organisation to ensure that we can continue to maximise the local benefit from the support provided: All organisations have agreed and are committed to supporting this programme of work at board level and pragmatic arrangements are put in place for decision making across organisations in the local health economy; Stakeholders are amenable to receiving external support and buy into the principle of the programme; Stakeholders across the local health economy sign up to the programme of work and the agreed timescales for its delivery. If any stakeholders identify any risks to these assumptions I would ask that you highlight this as soon as possible to the local project team and your contact: TDA: Gemma Stanion; NHSE: Paul Bennett or Monitor: Faizal Mangera, as soon as possible so that we can work together on a resolution. Yours sincerely Alwen on behalf of Alwen Williams, Anne Rainsberry & Mark Turner 31 4

32 Appendix 1 Governance structure for the NEL CHE Programme 5 32

33 CCG CONTRACTS Update to CCG Board & Next Steps April

34 CONTEXT The March CCG Board meeting Approved the plan to invite the GP Federation to develop proposals to provide a number of list based services which are successors to local enhanced services This paper Provides an update Confirms the legal advice on contractual arrangements Recommends the next steps 34

35 PROCESS TO DATE The CCG Board agreed that each Programme Board would identify Key Lines of Enquiry (KLOEs) for each proposed contract and invite a response from the Federation These were considered by the individual Programme Boards who made recommendations to the CCG Contracts Sub Committee Jamie Bishop (Chair); Christine Blanshard; Paul Haigh; Philippa Lowe; Rhiannon England; Jenny Singleton, Anna Garner Each of the Programme Boards recommended that the CCG enters into contracts with the Federation These recommendations were reviewed by the Sub Committee on 9 April and endorsed In doing so the Sub Committee identified some further questions for the Federation to test its organisational capacity and capability as part of a process of due diligence 35

36 DUE DILIGENCE EXERCISE The Audit Committee on 10 April noted the discussions of the CCG Contracts Sub Committee and endorsed the following recommendations The CCG should initiate a piece of due diligence to test the organisational capacity of the Federation This would be based on the due diligence undertaken during the procurement of the OOH provider and on the questions posed by the CCG Contracts Sub Committee and Audit Committee The CCG Contracts Sub Committee would develop and recommend the due diligence questions to the Audit Committee for agreement and would lead the due diligence assessment The outcome will be reported to the CCG Board 36

37 OVERHEADS In its responses, the GP Federation has requested overheads of 15% in addition to the service contract sums proposed The CCG has asked the Federation to provide more information on the proposed use of any overheads and will need to consider this against potential savings in current CCG budgets and in the context of the start up of the Federation and the due diligence exercise The CCG Board is asked to note that the CCG Contracts Sub Committee will review the overheads proposals and make a recommendation to the CCG Audit Committee to ensure it can make an assessment of the value for money of any additional costs incurred in commissioning services in this way. 37

38 LEGAL ADVICE The Audit Committee on 10 April also reviewed the attached legal advice from Beachcrofts The CCG Board is asked in particular to Note section 6 and the rationale for entering into a contract with the GP Federation without a full procurement exercise Note that if the GP Federation is not fully set up the CCG could enter into a contract with CHUHSE (out of hours provider) and agree to novate the contract to the Federation in due course (option 3 in section 7) 38

39 CCG BOARD DECISION The CCG Board is asked to Note the work and recommendations of the CCG Contracts Sub Committee and Audit Committee Note the due diligence process Consider the legal advice Support the recommendation to enter into contract dialogue with the Federation for a contract commencing on 1 July 2014 to 31 March 2016 subject to a successful due diligence outcome 39

40 HANDLING CONFLICTS OF INTEREST Both the Sub Committee and Audit Committee endorsed the helpful input and advice of Dr Rhiannon England as a CCG GP (Mental Health lead) who doesn t work in a local practice and therefore has no conflict of interest in the recommendations. The Audit Committee had also used NHSE recommended code of conduct templates to review the recommendations from the Programme Boards on the original service specifications and recommendations but had not had the benefit of clinical advice in these reviews Both Sub Committees noted that Dr England would not be able to provide this function on an ongoing basis Both Sub Committees agreed to recommend to the CCG Board that a GP from outside the CCG is appointed on a sessional basis to Provide ongoing clinical GP advice specifically to the CCG Contracts Sub Committee and to the Audit Committee but also across the CCG governance in situations where local GPs have conflicts of interest and cannot provide independent clinical input Provide support to the CCG in contract monitoring and quality assurance of the GP Federation The Board is asked to support this recommendation and ask the CCG Chief Officer to advertise the post The Board is also asked to note the CCG has asked Beachcrofts to support the development of the arrangements for contract monitoring of the Federation to ensure that these mitigate conflicts of interest 40

41 NHS CITY & HACKNEY CLINICAL COMMISSIONING GROUP ADVICE REGARDING THE COMMISSIONING AND CONTRACTING FOR ENHANCED SERVICES 1. EXECUTIVE SUMMARY 2. SCOPE 1.1 The direct award of LES to either CHUHSE or the GP Federation by the CCG may carry legal procurement risks. However, if the CCG can demonstrate that the services in question are genuinely list-based (i.e. the GPs with patient lists are the only capable providers in providing these services) this will help to mitigate the risk of a successful challenge under the 2013 Regulations. 1.2 This is further complicated as the direct award by the CCG is proposed to be to CHUHSE / the GP Federation, rather than the GP practices themselves. There is an argument that could be made that CHUHSE / the GP Federation is simply a corporate vehicle that the GPs are using for the purposes of organising themselves and for the best allocation of the various services, and again, if this can be successfully demonstrated, risk is further mitigated. 1.3 If the CCG does proceed to directly award the contract to CHUHSE (in the first instance) it could either: Award a short term contract to CHUHSE, allowing for the GP Federation to be set up, and subsequently (on contract expiry with CHUIHSE) put in place a new contract with the GP Federation; or Award a contract to CHUHSE and seek a separate commitment from CHUHSE to novate to the GP Federation at a particular trigger point, then enter into a novation once the GP Federation has been set up. 1.4 The CCG should carefully consider its rationale for directly awarding the LES to one provider and document the same. A demonstration of how the provider is the only capable provider (or in the alternative, the most capable provider that provides value for money) will help to mitigate a successful complaint to Monitor by a provider under the 2013 Regulations. The CCG may also be able to demonstrate arguments on the basis that going out to competitively tender these services would be disproportionate to the value, complexity and clinical risk of these services. 1.5 Regulation 9 of the 2013 Regulations requires CCGs to publish a record of each contract it awards for the provision of health care services for the purposes of the NHS. This includes a requirement to publish the contract value. The CCG should be mindful of this requirement, and ensure that it is complied with. 1.6 The CCG should carry out due diligence and be satisfied with the financial robustness of CHUHSE / the GP Federation when considering a direct contract award / allowing a novation of a contract to the relevant provider. This will include considering the insurance arrangements, and obtaining financial guarantees where necessary, to support any newly formed corporate vehicle with no trading track record. 2.1 NHS City and Hackney Clinical Commissioning Group (the "CCG") is currently formulating its strategy for commissioning ex-local enhanced services (referred to as "LES" in this paper for ease of reference) from April 2014 onwards. 2.2 The CCG considers that LES are services that can only be provided by GP practices in order to ensure that there is population coverage _1 Page 1 of 10 41

42 2.3 We understand that the CCG is considering awarding the LES directly to a federation of GP practices ("GP Federation"), which is to be formally, established in the near future. The membership of the GP Federation will consist of all GP practices within the CCG area. 2.4 It is envisaged that the GP Federation will be set up as a corporate vehicle (which may be a social enterprise), however, it may not be set up as such by the time that the contract for LES will need to be put in place by the CCG. The GP Federation will have a shared management structure with the current provider of GP out of hours services, the City and Hackney Urgent Health Social Enterprise ("CHUHSE"). 2.5 We have been asked to advise the CCG as to its contracting options if the GP Federation is not formally established by the time the CCG decides to enter into contractual arrangements for LES, and in particular: whether the CCG could award the LES to CHUHSE, with a subsequent novation to the GP Federation once it has been formally set up; and whether there are any alternative ways to enter into a contract for LES if the GP Federation is not yet in operation. 2.6 We understand that the CCG's objective is to award one contract for LES, rather than multiple contracts to different GP practices. 2.7 This paper sets out advice on the issues noted above, against the backdrop of the potential procurement issues and associated risks. We have only considered commissioning issues at this stage. 3. BACKGROUND 3.1 LES were previously commissioned by PCTs in response to local needs and priorities. In commissioning those services (as with their other commissioning) PCTs were required to comply with procurement law and the Principles and Rules of Cooperation and Competition ("PRCC") insofar as they were applicable. 3.2 The position changed in terms of the responsibility for the commissioning of LES services from 1 April 2013 with the dissolution of PCTs. The NHS Commissioning Board ("NHS England") is responsible for the GP contract but wants CCGs to be able to commission a wide range of community based services outside of the scope of the GP contract. 3.3 In addition, Parliament has approved the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013 (the "2013 Regulations") which came into force on 1 April The 2013 Regulations replace the PRCC and set out a number of obligations on both NHS England and Clinical Commissioning Groups when procuring services. The 2013 Regulations apply to CCGs. Monitor has also produced guidance in relation to the application and enforcement of the 2013 Regulations that can be found here: The CCG will therefore need to be mindful of the specific risks in commissioning LES where the GP practices (who are the members of the CCG) are also the potential providers of the services that they are commissioning. Given that other areas of primary care will not be commissioned by the CCGs, this raises a risk that there will be more focus on the operation of conflicts and competition in the commissioning of LES by CCGs than there was with PCTs. 3.5 Historically, many local enhanced services required access to GP-held patient information (and arguably, the patient lists themselves, held by GP practices) and are _1 Page 2 of 10 42

43 frequently of such low volume and value that they have not been competitively tendered. 4. COMMISSIONING OPTIONS 4.1 Guidance from NHS England states that the CCG should consider one of three commissioning routes where GPs are potential providers of the service, as is the case here. These are: 1. a full competitive tender; 2. single tender award without competition; or 3. an Any Qualified Provider ("AQP") framework. 4.2 Note that under the 2013 Regulations, the CCG may award a contract for the provision of health care services to a single provider without advertising an intention to seek offers from providers in relation to that contract, but only where the CCG is satisfied that the services to which the contract relates are capable of being provided only by that provider. In this case, you have confirmed that the services can only be provided by GP practices. 4.3 The main options for the CCG and the related commissioning routes/issues are therefore briefly summarised in Table 1 below. We have highlighted in blue the options that we understand are most likely to be followed by the CCG, given the scope of our brief: Table 1 1a 1b Commissioning Option All LES opened to competition for the award of a fixed term contract LES services are categorised by the CCG between those which can only be provided by the local GP (which are awarded to the relevant GP practices) and other services (which are competed by full competitive tender) 2 All or some LES services awarded to single provider (including for example any of the GP Practices, the GP Federation or CHUHSE) Commissioning Route Full competitive tender Mixed: part single tender award, part full competitive tender Single tender award Key issues 1 Consider whether there is a market for the services in this form. 2 Consider whether only a GP provider would be capable of providing all of the LES services. 3 Managing any conflicts of interest in the process with GP Provider involvement as bidders. 1 The CCG will need to manage any conflicts of interest in the process and selection of specific LES service lines for competition. 2 Consider whether there is a market for the LES services which are competed by the CCG. 3 Consider how value for money and quality are assessed and protected in a single tender award and the impact if there are other potential providers. 1 Risk of breach of procurement rules (including the 2013 Regulations) where other providers are excluded. 2 Impact on patient choice under the 2013 Regulations. 3 Given higher value through 'bundling' the LES services it is unlikely to be considered a contract of minimal value _1 Page 3 of 10 43

44 Commissioning Option without competition 3 All (or some) LES awarded to a GP practice directly (and then subcontracted to other GP providers as required) 4a 4b Specific LES service lines are categorised as those which are only capable of GP provision (which are awarded to the relevant GP practices) and other services are opened out to the provider market generally through AQP to allow patient choice All or some LES advertised as an AQP framework to open up the services to potential competition Commissioning Route Single tender award Mixed: part single tender award, part AQP Full competitive tender under AQP Key issues 4 If a contract is awarded to a separate entity then this is in effect awarding a new provider the contract and weakens the argument that only the local GP practice could deliver the service. 5 Consider whether there is a market for the LES services which are competed. 6 Consider how value for money and quality are assessed and protected in a single tender award and the impact if there are other potential providers. 1 Risk of breach of procurement rules (including the 2013 Regulations) where other providers are excluded. 2 Impact on patient choice under the 2013 Regulations. 3 If the LES services are not being provided by the local GP practices in any event it weakens the argument that they are the only capable provider and increases the risk of challenge that other providers are being excluded. 4 Managing any conflicts of interest with GP provider involvement. 5 Consider how value for money and quality are protected in a single tender award and the impact if there are other potential providers. 6 May be difficult to find one GP practice that wishes to take on the risk and responsibilities associated with being lead provider. 1 Consider whether there is more than one possible provider for the services under AQP. 2 There will still be a need to assess how the referrals are operating as an ongoing basis to verify that any conflicts are being managed. 3 Consider the cost of maintaining an AQP panel if there are multiple providers interested. 4 Consider the impact on the provider market of the uncertainty of an AQP approach (zero value contract and value based on patient choice against set tariff). 1 Consider whether there will be a market for the services in this form. 2 The CCG will need to manage any conflicts of interest in the process with GP Provider involvement as bidders and in the selection of specific LES service lines for competition. 3 There will still be a need to assess how the referrals are operating as an ongoing basis to verify that any conflicts are being managed. 4 Consider the cost of maintaining an AQP panel if _1 Page 4 of 10 44

45 Commissioning Option Commissioning Route Key issues there are multiple providers and impact on market. 5. RISKS OF PREFERRED COMMISSIONING OPTIONS 5.1 We have set out the overarching procurement law considerations as well as some further detail regarding the AQP route, in the Annex to this advice note. 5.2 If the CCG is seeking to directly award LES to a single provider, it would be open to other providers to challenge such a decision (for example, any GP practices or other providers that wish to provide LES but are not given the opportunity to bid, or indeed are not sub-contracted by the lead provider). This may be the case whether the lead provider is another GP practice, CHUHSE or the GP Federation. 5.3 If the CCG decides to directly award a contract to a single provider without competition, the CCG's will need to document the reasons and the justification for doing so to assist the CCG to respond to challenges (see below). Commissioning Option 2: Award to a single provider (including any GP practice) without competition. 5.4 Awarding the contract to a GP practice, CHUHSE or the GP Federation without carrying out a procurement process presents a risk of challenge (in particular, under the 2013 Regulations) where other potential providers were being excluded from the opportunity to provide the services. The aggregation of multiple LES into one CCGwide contract may create a contract with significant value, which would further exacerbate the procurement risk. 5.5 If the contract was awarded directly to CHUHSE, or indeed the GP Federation without competition, there could be a complaint to Monitor (under the 2013 Regulations) that the CCG was acting anti-competitively by restricting patient choice, and the LES were in effect apportioned between the GP practices through such a vehicle to cut out other potential providers from the market. There could also be a complaint under other grounds set out in the 2013 Regulations, including an argument that the CCG have not treated all providers equally and in a non-discriminatory way or that the CCG has failed to procure the services from a provider / providers that are most capable of providing the services. Commissioning Option 3: The CCG award LES contracts to each of the local GP practices for their relevant LES services on the basis that they were the only potential providers. 5.6 Insofar as the GP practice then provides those services to the patient (and the assessment is correct) then this would appear to be a low risk approach. 5.7 The argument for this is significantly weakened if the contract is then sub-contracted by a GP practice to other GP practices or a separate GP provider vehicle (i.e. if in effect the GP practice does not have the skills or intent to provide the specific services and the contract award is not genuinely to the only provider able to deliver the services involved). 5.8 To reduce risks, the CCG may consider splitting the services awarded in this option and running a competitive exercise where there is a market for LES services but awarding a contract to the local GP practice for the LES service lines where it is the only potential provider. 5.9 Also note that Regulation 9 of the 2013 Regulations requires CCGs to publish a notice of each contract it awards for the provision of health care services for the _1 Page 5 of 10 45

46 purposes of the NHS, which should include the name of the provider, a description of the services, the contract value, term and the process adopted for selecting the provider. 6. CONSIDERATIONS FOR USING A SINGLE PROVIDER/DIRECT AWARD WITHOUT COMPETITION 6.1 For services under LES where there are no other possible providers (e.g. if it can be clearly demonstrated that there is a clinical rationale for such services to be integrated with GP list-based care) then the CCG could consider awarding the services to the relevant GP practice without the need for a competitive procurement exercise. 6.2 This position is complicated if the contract is awarded to a separate entity (GP Federation or CHUHSE) as neither the GP Federation nor CHUHSE hold patient lists in their own right 1. For that reason, it is more difficult for the CCG to evidence that there is only one provider capable of providing LES, as the award of the LES contract to CHUHSE or the GP Federation will not be based on those entities holding the relevant patient lists. However, it could be argued that CHUHSE or indeed the GP Federation are simply vehicles that will be acting on behalf of all of the GP practices to organise themselves in order to be able to deliver LES in an effective, co-ordinated manner. 6.3 The easiest way to demonstrate that there are no other capable providers is to run a form of competitive exercise but the CCG could also show market tests or other data to this end. For example, if it can be demonstrated that no other providers but the GPs are able to provide the LES, and all of the GP practices in the CCG area agree that CHUHSE / the GP Federation are best placed to essentially triage the LES, this would further mitigate the risk of challenge. 6.4 Furthermore, the CCG could argue that CHUHSE are the only capable provider to deliver against the bundled LES as they can have the oversight of all the GP practices, to ensure that the services are delivered at the appropriate setting. If the CCG can clearly demonstrate the benefits to patients from this arrangement, this adds weight to the argument and mitigates risk of a successful challenge under the 2013 Regulations. We appreciate that there may be a "chicken and egg" scenario here, given that the services would need to be provided by CHUHSE / the GP Federation in order to clearly demonstrate the impact upon patients. 6.5 Given that one proposed option is for CHUHSE to hold the contract until such time that the GP Federation is set up, it would be difficult, following this approach, to argue that there is only one provider capable of providing the LES. A disgruntled provider in the market might raise a challenge on the basis that the management of LES could be undertaken by a number of other providers and therefore should have been put out to competition. Commercially, you might consider that such a challenge is unlikely to arise, however this will depend to a degree on the value of the bundled LES. 6.6 However, a possible justification for this is that a single provider is required as it would otherwise be very difficult for the CCG to manage quality and efficiency of service provision in accordance with its obligations under the 2013 Regulations. We understand that the GP Federation's operating model and leadership arrangements are being designed to assist the CCG to discharge these statutory duties on a practical day to day basis. 1 Please confirm that this is correct. Another way to mitigate the risk would be to only award a short-term contract. This would allow for the CCG to move to an alternative competitive process should the market position change. The CCG should note the potential sanctions (see the _1 Page 6 of 10 46

47 Annex) which include Monitor declaring that a contract is ineffective where the CCG has breached the 2013 Regulations. At this stage, the enforcement of the 2013 Regulations is at an early stage, and Monitor has sought to allay fears that it will take a draconian approach in recent seminars that it has been presenting at across the country. 6.7 The CCG will also need to be wary of any conflicts of interest in taking this decision as there are clear risks where GP practices are both members of the commissioning body and prospective providers. The CCG must manage any conflicts of interest and ensure that such conflicts do not corrupt (or appear to corrupt) the integrity of the decision making process. If the GP practices are the only capable providers, consideration should be given to how this decision is reached and documented and also how the CCG have assured the quality of the services before the CCG awards the contract. It would be worth ensuring the market was reviewed regularly enough to be confident that the CCG is getting value for money and has awarded to the right provider from a quality perspective, and for this reason we have recommended a short term contract in the first instance (see below). 7. CONTRACTUAL ISSUES AND NOVATION 7.1 From a contractual perspective, it is open to the CCG awarding the contract for LES (which will be based on the NHS England Standard Terms for 2014/15) to either CHUHSE or the GP Federation (once the corporate joint venture has been set up). 7.2 The main options for the CCG to structure the contractual arrangements, given that the CCG has instructed us to focus on options for awarding one contract only are: Option 1: award a short term contract (e.g. 6 months) to one of the GP practices that has the capacity to act as lead provider for the LES, and will be in a position to manage the contract and sub-contract services where necessary; Option 2: award a short term contract (e.g. 6 months) to CHUHSE to allow the GP Federation to form a corporate joint venture, and on expiry of the contract, award the replacement contract directly to the GP Federation; or Option 3: award a contract to CHUHSE and then novate the contract from CHUHSE to the GP Federation. 7.3 These options also carry the same procurement law issues that we have set out in this advice note, and therefore they should be viewed in light of those risks. 7.4 Option 1 arguably carries a higher procurement risk, given that the CCG would be awarding a single contract to one of the GP practices without a competition. On that basis, it would be difficult to argue that there is only one provider capable of providing the LES as you would effectively be choosing one GP practice from among many, and the CCG would be devolving responsibility to that GP practice to sub contract the provision of LES to various other GP practices. There is also more scope here for other GP practices to seek to challenge the decision to award one GP practice with the role of lead provider. 7.5 For this reason we have decided to focus on contractual options 2 and 3. Contractual Option 2: Award a short term contract to CHUHSE 7.6 The GP Federation is unlikely to be set up as a corporate joint venture prior to the LES contract award date. Awarding a short term contract to CHUHSE while the GP Federation is being set up would allow the CCG to contract for the LES on a short term basis whilst ensuring the appropriate oversight and population coverage in the interim by a provider that has the same / similar membership of the nascent GP Federation _1 Page 7 of 10 47

48 7.7 Practically, as CHUHSE and the GP Federation share a management structure, one would expect that any transition from CHUHSE to the GP Federation will be smooth and it will ensure minimal disruption to patients. 7.8 However, unlike a novation, the liabilities for the services provided by CHUHSE would remain with CHUHSE (rather than transferring to the GP Federation). Depending on the scope of LES, this might be commercially acceptable to the CCG, especially given that CHUHSE has been selected as the CCG's current out of hours provider, following a competitive procurement exercise. Staffing issues may also need to be considered if the GP Federation takes over service provision from CHUHSE (i.e. will any staff transfer by TUPE?). 7.9 Although two separate contracts will need to be agreed, but given our comments above in relation to the same management structure of CHUHSE and the GP Federation, this might not be an issue in practice There is the risk with both contractual options 2 and 3 that the GP Federation may not agree to the obligations of the contract and may seek to renegotiate, but this contractual option avoids the risk of obtaining CHUHSE's additional consent to novate and give up the services at a later date. Contractual Option 3: Novate the contract from CHUHSE to the GP Federation 7.11 It would be possible, under general contract law, to novate the contract from CHUHSE to the GP Federation, however the novation would require the consent of the CCG, CHUHSE and the GP Federation to be valid The novation would technically terminate the original contract releasing CHUHSE (the outgoing provider) from its obligations and any future liabilities and would replace it with a new contract under which the GP Federation (the new provider) undertakes to be bound by the rights and obligations From the CCG's perspective, the concern will be how to ensure that CHUHSE will agree to this novation further down the line. An option could be to seek to enter into a side letter between the CCG and CHUHSE confirming their consent to novate the contract to the GP Federation at a particular, well defined trigger point. This will need to be as specific as possible to avoid the risk of being considered merely an agreement to agree As stated above, the novation of the LES contract from CHUHSE to the GP Federation would undermine the argument that there is no alternative provider and thus no need to tender the contract. Due diligence 7.15 Whichever option is decided, the CCG should ensure that it undertakes the requisite due diligence on the providers involved, to ensure that they are financially robust organisations (or at the very least, appropriately backed), that the required insurance arrangements are in place and that the organisation is (if relevant) registered for the relevant regulated activities with the Care Quality Commission. 8. CONCLUSION 8.1 Please see our executive summary above. 8.2 Should you have any questions in respect of the issues raised in this paper, please do not hesitate to contact us. DAC Beachcroft LLP 3 rd April _1 Page 8 of 10 48

49 ANNEX The overarching procurement obligations for LES The CCG are a "contracting authority" for the purpose of the Public Contracts Regulations 2006 (as updated and amended) (the "2006 Regulations"). When awarding contracts, the CCG will therefore have to have regard to the 2006 Regulations where appropriate and specifically, the principles of transparency, equal treatment and non-discrimination (the "Overriding Treaty Principles"). The CCG will also have to comply with relevant guidance from NHS England and the 2013 Regulations. As the CCG will be both (through its members) a provider and commissioner of LES, the CCG will have to ensure that the CCG manage any potential conflicts of interest appropriately. LES are Part B services for the purpose of the 2006 Regulations. Part B services must comply with the Overriding Treaty Principles where there is no cross border interest (meaning it is unlikely providers in other member states in Europe would be interested in providing the service) but are otherwise not subject to the full application of the 2006 Regulations. We consider that LES are unlikely to be of cross-border interest. If the CCG does not follow a competitive process where it would have been appropriate to do so (i.e. where there are alternative service providers), then there is a risk that other capable providers could challenge the CCG under the 2013 Regulations or the 2006 Regulations. A challenge under the 2006 Regulations would be on the basis that the CCG had not complied with the Overarching Treaty Principles and if the challenge was successful (in that it was taken to Court and upheld), then the challenger may be awarded damages to the amount of the profit they would have made had they won the relevant contract. In terms of likelihood of challenge on this basis, from our experience success rates are relatively low. Under the 2013 Regulations, another route for a potential provider to challenge would be via Monitor. Monitor has investigative powers to look into potential breaches of the 2013 Regulations when it receives a formal complaint. The sanctions Monitor may impose include declaring the contract, or any of its terms, ineffective (i.e. void) and directing the CCG to rectify breaches of the 2013 Regulations. There is no time limit for potential providers to bring such challenges within. Monitor s substantive guidance on the 2013 Regulations states: Excerpt from Monitor's substantive guidance on the 2013 Regulations: "There is no requirement in the Procurement, Patient Choice and Competition Regulations for commissioners to publish a contract notice before awarding a contract to provide those services. When deciding how to procure services, including whether or not to publish a contract notice, commissioners will need to ensure that their decision is consistent with: their general objective, when procuring services, to secure the needs of people who use the services and to improve quality and efficiency including through the services being provided in an integrated way (Regulation 2 of the Procurement, Patient Choice and Competition Regulations); the requirement to secure that arrangements exist to enable providers to express an interest in providing any NHS health care services (Regulation 4(4) of the Procurement, Patient Choice and Competition Regulations); the requirement to act transparently, proportionately and not to discriminate between providers (Regulation 3(2) of the Procurement, Patient Choice and Competition Regulations); the requirement to commission services from those providers that are most capable of securing the needs of health care service users and improving the quality and efficiency of services, and that provide the best value for money in doing so (Regulation 3(3) of the Procurement, Patient Choice and Competition Regulations); and the requirement to consider appropriate means of improving NHS health care services, including through enabling providers to compete to provide services (Regulation 3(4) of the Procurement, Patient Choice and Competition Regulations)." _1 Page 9 of 10 49

50 Any Qualified Provider In order to set up an AQP framework as suggested under Commissioning Routes 4a and 4b, the CCG would need to have a clear specification of the LES services to be included and the price for these as, in effect, under AQP there should be no price competition. Therefore the CCG should consider if it is possible to set the fixed price for the services in this manner if the CCG are looking towards an AQP framework. This should be capable of being actioned in practice as LES services are currently set/negotiated at a uniform price. AQP would be an open framework on which any provider which met the applicable criteria (which would need to be set carefully and objectively so as not to exclude potential competitors unless it was appropriate due to their qualification to deliver the services) would be entered into a list which patients would select their preferred provider from. The CCG would need to have safeguards to ensure that patients are aware of the choice of providers available and that referrals are not skewed towards a particular direction (e.g. GP providers to the exclusion of other providers). AQP would need to be operated on a transparent basis as the CCG would be expected to publish the details of the framework (the services and the price) through the CCG s website and also the details of the providers who have qualified to provide the service. Each qualifying provider would be awarded a zero value contract with the CCG and would be paid for the volume of activity delivered from patients selecting them for the particular service. This obviously creates a more uncertain payment stream. There may be particular patient benefits of running this type of scheme. For instance, in running a Phlebotomy LES, it may be more appropriate for the patient and more convenient all round for Providers for phlebotomy services to housebound patients to have their bloods taken by Community Service providers. In this way a more flexible patient-by-patient approach to delivering services may be of benefit to patients and providers (GP and Community Services). There are also issues in adopting AQP in terms of: the potential administration burden where multiple providers are on the framework; and a need to have clear ongoing management of the conflicts of interest between GP practices as members of the CCG (who are referring patients) and providers. From a provider's perspective, AQP removes the certainty of income from the LES as this is determined by patient choice/activity _1 Page 10 of 10 50

51 FINANCE & ACTIVITY REPORT Month /14 NHS CITY & HACKNEY CCG BOARD MEETING 25 April 2014 NHS City & Hackney CCG 51

52 Contents Executive summary Finance and activity dashboard & trend Key risks narrative Running costs performance Financial Statements 52 NHS City & Hackney CCG

53 Executive Summary A review of Month 12 financial position and month 11 activity was undertaken as part of the year end process in compiling the M12 position. The declared FOT at M9 of 27,236k was met with a slightly improved surplus position of 27,266k. The position included a number of disputed items not resolved at year end, particularly with ELFT, NHS Property Services and Barts, as well as a provision for new CHC retrospective claims. All of these material items were known risks and have been part of discussions with external audit to ensure compliance with the year-end audit. Dashboard (page 4) highlights a GREEN RAG rating against the CCG I&E position. QIPP for M12 delivered a Green RAG rating Improving in the month of March in line with plan expectation. 53 NHS City & Hackney CCG

54 INCOME & EXPENDITURE MONTHLY ACTUAL YTD vs BUDGET EXPENDITURE YEAR END FORECAST v PLAN TREND THIS IS THE ACHIEVEMENT OF YTD PLAN, UNDERLYING PERFORMANCE AND PROJECTED FORECAST. 65m 55m 45m 35m 358m 353m 348m 343m 338m 4795 FINANCE DASHBOARD 25m 333m 15m m ACUTE SPEND HUHT SPEND VARIANCE vs PLAN (%) ALL ACUTE SPEND VARIANCE vs PLAN (%) NCA SPEND VARIANCE vs PLAN (%) 30% % % % 20% 10% TREND 10% 0% 10% 0% 5% 0% THIS IS THE ACUTE PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. -10% -20% -10% -20% -5% -10% -30% -30% -15% QIPP PRESCRIBING NON-ACUTE Sep Sep Total of pre GW3 CRES ideas - valued at 35% which is the % required to be achieved of general CRES schemes QIPP PERFORMANCE vs PLAN PRESCRIBING PERFORMANCE vs PLAN NON-ACUTE PERFORMANCE vs PLAN THIS IS THE DELIVERY OF QIPP AGAINST THE PROFILED ANNUAL PLAN. THE TREND REPRESENTS THE FULL YEAR DELIVERY AGAINST TARGET WHICH WAS 4% ( 0.2m) BEHIND TARGET THIS IS THE SPEND ON PRESCRIBING BASED ON THE PPA (PRESCRIPTION PRICING AUTHORITY) FORECAST VS ANNUAL PLAN. M12 WAS ON PLAN THIS IS THE SPEND ON MENTAL HEALTH, COMMUNITY HEALTH & CONTINUING CARE VS ANNUAL PLAN. M12 WAS OVERSPENT BY 5.65% ( 5.7m) 54 NHS City & Hackney CCG

55 Key Risks - Finance Key risks are quantified on Page 6 and are based on the main drivers behind the performance shown in the dashboard on Page 4. The M12 position is inclusive of the agreed contract position for HUH for which contract agreement was only concluded in M12. An agreed/acceptable position for Barts acute, UCLH and other providers Barts Health for M12 was reported as 1.7m adverse to full year plan and in line with FOT expectation. Data quality issues persist, including the continued risk of appropriate attribution of Specialist Commissioning and has not given assurance on the accuracy of activity reported. Homerton activity has been reviewed and validated across multiple areas which has resulted in a 1.1m overspend to full year plan. Contract negotiations were concluded early March with fine detail on the financial impact being reflected in the M12 position. Data quality and attribution issues continued to exist with a number of Providers at year end but the surplus position is inclusive of applicable risks and pressures. Actions: Non-acute over-performance on Continuing Health Care has been subject to a detailed review as the situation worsened over a several month period. Serious concerns still remain over the integrity and administration of the Broadcare system operated by CSU, however, they have reported that the situation has stabilised, but the promised deep dive report was not delivered. The CCG is seeking a full explanation of where the additional demand has been generated from in order to determine any remedial action needed. An internal audit review has identified significant improvements in the management of this area. Prescribing expenditure in total was underspent 353k. The favourable position is inclusive of prior period charges having been investigated and corrected and completion of work to address the matter of the cost of drugs incorrectly charged to C&H CCG by the Prescription Pricing Authority instead of the Local Authority. The CCG has disputed invoices raised for the Specialist Addiction Unit (SAU) and Charged Exempt Overseas Visitors (CEOV), but these remain unresolved at year end and the CCG has taken a prudent view on where the liability sits. Programme Costs were overspent by 933k on a full year basis due to a restatement from Running Costs in line with guidelines on definitions agreed by the London CCGs, supported by NHSE. The overspend is offset by an underspend of the same amount reported as part of the variance within Running Costs. Action: CSU to maintain and deliver on CHC administration and control systems, and identify the drivers for the overspend. QIPP on a full year basis under delivered against target by 202k, mainly on planned and urgent care, but was in line with expectation. 55 NHS City & Hackney CCG

56 Running Costs Performance on CCG Running Costs are shown below. The CCG is not permitted to exceed its allocated Running Cost Allowance, but is permitted to allow any unspent balances to be used for Commissioning. The total allocation is 6.54m and the full year spend was 4.93m The underspend on Running Costs is due to vacancies, restatement to Programme Costs and an uncommitted contingency. For M12 close there was an improvement in the favourable year to date variance of 379k as applicable expenditure was moved to Programme Costs in-line with agreed guidance. Monthly Running Costs vs. Plan Total Planned Spend CCG Planned Spend CSU Planned Spend 56 NHS City & Hackney CCG

57 Key Risks - Activity The key risks behind the dashboard variances are reported here and reflect the recommendations of the review carried out at the Finance and Performance Committee Refreshed graphs on slide 8 were not available at the time this report was compiled. The activity presented was reported at M NHS City & Hackney CCG

58 ACUTE ACTIVITY PLANNED CARE ACTIVITY ALL PLANNED ADMISSIONS VARIANCE vs PLAN (%) ALL OUTPATIENT VARIANCE vs PLAN (%) 60% 50% 40% % 60% 50% ACTIVITY DASHBOARD TREND 30% 40% THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. 20% 10% 0% 30% 20% 10% 0% -10% -10% URGENT CARE ACTIVITY ALL A&E ACTIVITY vs PLAN (%) ALL ADMISSIONS vs PLAN (%) HUHT ADMISSIONS vs PLAN (%) 50% % % % 40% 40% TREND 30% 30% 30% THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. 20% 10% 20% 10% 20% 10% 0% 0% 0% -10% -10% -10% Refreshed graphs were not available at the time this report was compiled. The activity presented was reported at M NHS City & Hackney CCG

59 Financial Statements - 1 INCOME & EXPENDITURE ACCOUNT Annual Budget 000 YTD Budget 000 YTD Actual 000 YTD (Under)/Overs pend 000 Forecast Actual 000 Forecast (Under)/Overs pend 000 Improvement/ Deterioration vs Month 11 Improvement/ Deterioration vs Month 11 '000 In Sector Acute Trusts 127, , ,616 2, ,616 2,094 1,332 Out of Sector Acute Trusts 36,512 36,512 40,870 4,358 40,870 4, Other Acute 9,855 9,855 6,604 (3,251) 6,604 (3,251) 430 Subtotal Acute 173, , ,090 3, ,090 3,202 2,084 Mental Health 48,291 48,291 51,444 3,154 51,444 3,154 3,278 Community Health 37,235 37,235 37, , Other Non Acute 16,455 16,455 18,898 2,443 18,898 2,443 (254) Subtotal Non Acute 101, , ,736 5, ,736 5,756 3,277 Prescribing 29,596 29,596 29,243 (353) 29,243 (353) 253 Other Primary Care Services 8,154 8,154 8, , (166) Subtotal Primary Care 37,750 37,750 37,449 (301) 37,449 (301) 87 NHS Property Services ,018 2,143 3,018 2, Reserves 33,452 33, (33,053) 399 (33,053) (5,043) QIPP TOTAL CSU 347, , ,693 (22,254) 325,693 (22,254) 424 Corporate 6,540 6,540 4,932 (1,608) 4,932 (1,608) (560) TOTAL CORPORATE 6,540 6,540 4,932 (1,608) 4,932 (1,608) (560) GRAND TOTAL 354, , ,625 (23,862) 330,625 (23,862) (136) TOTAL RESOURCE LIMIT (357,891) (357,891) (357,891) 0 (357,891) 0 0 (SURPLUS)/DEFICIT (3,405) (3,405) (27,266) (23,862) (27,266) (23,862) (136) 59NHS City & Hackney CCG

60 Financial Statements - 2 KEY BALANCE SHEET INDICATORS Days Over Aged Debtors k 1.2 x 18,000 16,000 14,000 12,000 k 10,000 8,000 6,000 4,000 2,000 0 Actual Month End Cash vs Maximum Cash Holding Max Actual Compliance with Public Sector Payment Performance Target 94.1% The cash balance as at close of March was 190k and within the prescribed cash holding limit of 250k. During the month sizable payments were made to clear outstanding balances following the conclusion of contract negotiations. 60 NHS City & Hackney CCG

61 Financial Plan NHS CITY & HACKNEY CCG BOARD MEETING 25 April 2014 NHS City & Hackney CCG 61

62 Overview The CCG s draft 5 year Financial Plan was presented to the Board on 28 February 2014 with an update on key changes reported to the March meeting. This report summarises the final plan submitted to NHS England on 4 April The Plan assumes delivery of strong financial performance, significant investment in service transformation led by Programme Boards, realistic assessment of savings delivered from transformation and efficiency measures and a good headroom for effective management of risk. Greater certainty over key risk areas is assumed compared to 2013/14 when NHS commissioning arrangements were being reorganised. This paper covers: Allocations Expenditure and key assumptions driving costs Reserves 2 Year QIPP plans 2 Year Investment proposals Risks and mitigation There may be a further iteration of the Plan once all CCG and Provider plans have been consolidated across the NHS, but the CCG 2014/15 annual budget will reflect the assumptions in this plan. 62 NHS City & Hackney CCG

63 Overview - 2 The CCG is forecasting a surplus of 27m each year of the five year plan allowing for phased non-recurrent investments and QIPP. The 27m represents the roll forward through the model of the surplus delivered in 2013/14. Drawdown of surpluses from NHS England has been limited as nationally insufficient resource was set aside to cover it after the allocation process. The CCG has a number of pre-committed investments from 2013/14 which will start in 2014/15 and be funded in 2014/15, which includes readmissions and emergency tariff penalty investments. The CCG performs well against most benchmarks, has a history of effective clinical commissioning and pathway redesign and will continue to invest in transformation to remain one of the best performing CCGs and will enable the CCG to manage demand effectively. Investment is managed through the CCG Investment and Prioritisation Committee and most of the planned investments are in the process of agreement with providers and being built in to contracts or offered as contract variations. Investment is to drive incremental and evidence based change, rather than major transformation programmes; this approach has been successful over many years. The CCG has built 5m- 7m QIPP in each year of its plans for 2014/15 and 2015/16, these sums are the risk adjusted values and but each Programme Board will target much more ambitious levels of delivery. The CCG is expecting significant benefit in quality return and financial return from its investment. The key risk to the plan is that investments will not deliver benefit for future years and that demand is significantly higher than plan, although the CCG is holding a 1% contingency and would seek to either reduce NR investments or drawdown on the 27m surplus in future years to meet any financial gap that arose. The CCG has assumed contributions in to risk share arrangements in WELC (which reverses in later years) and the national risk pool to cover payments of retrospective continuing healthcare claims, even though these had previously provided for by the former PCT. The CCG has built in sufficient capacity to withstand risk. The CCG is planning to be well within its Running Cost Allocation and any surplus will be used to commission patient services. 63 NHS City & Hackney CCG

64 Summary The table shows the CCG allocation with the growth announced for 2014/15 and 2015/16 and a projection for future years. The Plan includes the return of previous years surplus and the addition of the Better Care Fund Allocation in 2015/16. The planned surplus exceeds the minimum 1% requirement, rolling forward the 2013/14 surplus year on year. '000 Closing 2013/14 Allocation bl 2014/ / / / /19 Running Costs 6,540 bl 6,565 5,926 5,943 5,959 5,974 The CCG receives a separate allocation for running costs calculated which has been frozen in 2014/15 and a 10% reduction in 2015/15. per head of constrained population. Funding can be moved to Programme activities (the table above), but not vice versa. 64 NHS City & Hackney CCG

65 Allocations * The table shows the CCG allocation with the growth announced for 2014/15 and 2015/16 and the separate running cost allocation. These sums are projected for a further 3 years. The Plan includes the return of previous years surplus and the addition of the Better Care Fund Allocation in 2015/16 (which is mostly the current s256 agreement between NHS England and LBH/CoL spent on local social care services related to health). The allocation for GPIT has not been included, neither has the matched expenditure; the allocation for this has been severely cut for C&H due to a national formula being introduced The new funding formula is based on a weighted allocation per head of population. As C&H is funded above the national target, the CCG will receive only minimum growth for the next 2 years, which moves the CCG closer to target per the last row in the table. 65 NHS City & Hackney CCG

66 Spending Plans & Reserves 1 1 Reductions due to removal of nonrecurrent investments 2 2 Increase due to nonrecurrent reserves not yet allocated to service line and includes the BCF The table shows the CCG spending plans by service area. These plans remain best estimates on contract settlements, many of which have yet to be confirmed. but include the impact of known QIPP schemes, investments and tariff efficiencies. Running costs are assumed to match the allocation, although likely to have a surplus in 2014/15 which can be used for patient services. The CCG Plan includes a number of reserves and contingencies. These include a mandatory contingency and mandatory non-recurrent reserve, emergency tariff and re-admissions funding arising from penalties on providers for exceeding target levels which the CCG plans to reinvest. Planned investments are included in Other Programme costs, which includes deferred 2013/14 investment and also include risk share contributions assumptions. A contingency sum of 1% is being held. 66 NHS City & Hackney CCG

67 Key Assumptions The table opposite shows the assumptions the CCG has used in its plans to calculate change from 2013/14 forecast outturn. Allocation assumptions have been nationally agreed for 2 years. Provider efficiency is based on national assumptions as these are only set for 2014/15. Demographic growth is prudently estimated at the 2013/14 assumptions. The allocation assumes 1.16%, but this has only been used in the final three years. The contingency is mandated at 0.5%, but the CCG is planning 1%. The mandatory non-recurrent strategic investment reserve (headroom) reduces to 1% in 2015/16 as the BCF starts. Running costs per head fall significantly over the 5 years of the plan in line with announced allocation. This potentially risks the CCG being unable to manage its business in the future with adequate resource, but a continued focus on staying lean should mitigate the risk. 67 NHS City & Hackney CCG