Croydon Clinical Commissioning Group Governance Arrangements

Transcription

1 Croydon Clinical Commissioning Group Governance Arrangements 31 October 2012 Rev. V10

2 Contents 1. Introduction 3 2. Internal Governance Structures The Governing Body 2.2 The Governing Body Committees 2.3 The Senior Management Team 2.4 Specific Areas of Governance (Safeguarding and Recovery) 3. External Governance Structures NHS Commissioning Board 3.2 Commissioning Support 4. Capacity to Deliver 8 Appendix 1 Safeguarding Governance 9 Appendix 2 Recovery Governance 15 Appendix 3 Appendix 4 Statement of Intent: SWL Primary Care Team in Preparation for the NHS Commissioning Board 23 Statement of Intent: Collaboration between CCGs and Specialised Commissioning 26 Appendix 5 Croydon Clinical Commissioning Group: The Commissioning Model 29 Appendix 6 Memorandum of Understanding and Framework: South London Commissioning Support Unit 37 Appendix 7 Integrated Commissioning Unit with the Local Authority 52 Appendix 8 Memorandum of Understanding: Public Health 59 Appendix 9 Framework for Collaboration: South West London Clinical Commissioning Groups 65 Appendix 10 Framework for Collaboration with South East London Clinical Commissioning Groups: Mental Health 90 Appendix 11 CCG Clinical Leaders Portfolios 92 Appendix 12 Croydon Strategic Transformational Board Health and Social Care Integrated Care Development: Terms of Reference 94 Appendix 13 South London Commissioning Support Unit: Specification Appendix 14 South London Commissioning Support Unit: Structures Appendix 15 CCG Structures Sep Doc Sep Doc Sep Doc 2

3 1. Introduction In accordance with section 14L(2)(b) of the 2006 Act, NHS Croydon Clinical Commissioning Croup (CCG) will at all times observe such generally accepted principles of good governance in the way it conducts its business. These include: the highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the organisation and the conduct of its business; The Good Governance Standard for Public Services; the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the Nolan Principles ; the seven key principles of the NHS Constitution; the Equality Act 2010; and the Standards for Members of NHS Boards and Governing Bodies in England (once published). This document sets out the governing arrangements of the CCGs Governing Body and together with the CCGs constitution sets out how the CCG will deliver its strategic visions below whilst discharging its duties to ensure effective governance arrangements are in place. 3

4 2. Internal Governance Structures The CCG must ensure both its internal and external governance arrangements are in clear and transparent. Set out below is the CCGs internal governance structures. Diagram 1: Internal Governance Structure 2.1 The Governing Body The membership of the governing body is set out in the constitution, along with the responsibilities of the clinical leaders and member practices. 2.2 The Governing Body Committees Under the Constitution the Governing Body has established: an Integrated Governance and Audit Committee (which shall be chaired by one of the Governing Body s lay members), which shall have a Finance Sub Committee and a Remuneration Committee. The Governing Body is able to establish other Committees as it deems necessary. The Terms of Reference for these committees are in Appendix 12 of the Constitution 2.3 The Senior Management Team Lead by the Chief Officer, the Senior Management Team is responsible for the day to day operations of the CCG and includes GP governing body members and clinical leaders. It is envisaged that the Senior Management Team will ensure the effective support to the Governing Body and its committees to ensure they can discharge their responsibilities effectively. In order to do that the CCG directors have key areas of responsibility as set out in Diagram 2 below. 4

5 Diagram 2: Functions by Director The directors will manage their responsibilities through a number of formal groups responsible to the Senior Management Team. Diagram 3 demonstrates these to date. Although SMT may establish more as it deems necessary. Diagram 3: Formal Groups of the Senior Management Team Attached as Appendix 12 is the Strategic Transformation Board Terms of Reference of which provides the key vehicle for ensuring development and discussions with partners, including main providers, about long term plans and strategies. 5

6 2.4 Specific Areas of Governance The CCG recognises that there is a need to be explicit about specific areas of governance; these are detailed in the appendices: Appendix 1 sets out explicitly our safeguarding arrangements Appendix 2 sets out the detail of the recovery governance 3. External Governance Structures Below, Diagram 4 sets out the external relationships which require specific governance arrangements. It demonstrates those that the CCG is responsible for and those that the CCG is responsible for being a key member of. Diagram 4: External Governance Structure 3.1 NHS Commissioning Board The CCG recognises the role of the NHS Commissioning Board. Appendix 3 sets out the statement of intent describing how the CCG will work in partnership with the SWL Cluster Primary Care Contracting team as part of preparing for future work with the NHS Commissioning Board (NHSCB) to integrate commissioning where appropriate and improve quality of primary care, and particularly to take account of need and unexpressed demand. This statement of intent relates to the financial year 2012/13 and will be superseded once NHSCB policy describing the working relationship between NHSCB and CCGs is published. Set out in Appendix 4 is the Statement of Intent for collaboration with the London Specialised Commissioning Group. Specialised services will be commissioned by the NHS Commissioning Board (NHS CB) from April 2013 and probably in shadow form from October This statement of intent maybe superseded by national / NHS CB directives. 6

7 3.2 Commissioning Support The CCG Board is clear on the principles upon which it is seeking its commissioning support. In the context of the 25 per head allocation, the CCG recognises that it cannot afford to directly provide all of the commissioning functions itself. It proposes to commission/procure its commissioning support from elsewhere. Appendix 5 sets out the principles for developing its commissioning support model, the model and the value for money exercise undertaken to support the CCGs decision to seek, in the first instance, all of its commissioning support from two places: South London Commissioning Support Unit (CSU), which has passed the BDU authorisation check point 2 including cores services and enhanced services Appendix 6 sets out the MOU with the CSU. The SLA is expected to be signed in November. Integrated Commissioning Unit with the Local Authority (ICU) including health commissioning, strategy, service re-design and safeguarding Appendix 7 sets out the arrangements with the ICU. A Memorandum of Understanding is currently being developed and is expected to be signed by December. The CCG has held contingency monies within the 25 per head to allow for increased commissioning support if needed and to resource additional capacity to review the commissioning support service in the future and undertake a procurement process. The CCG must also work closely with Public Health to ensure Public Health support the CCG to deliver its priorities, but also to ensure the CCG can support delivery of public health priorities. Appendix 8 provides the draft Memorandum of Understanding with Public Health which is expected to be finalised in November. The also reflects the CCGs required public health input, support and advice and working with the CSU (for example the Individual Funding Request process, Performance reporting, public health information). 3.3 Collaboration Agreements with Other Clinical Commissioning Groups The CCG recognises the benefits of collaborating with other CCGs. Appendix 9 sets out the collaboration agreements across South West London CCGs. Croydon CCG is part of the following specific areas of collaboration. Acute commissioning Non acute commissioning Out of hospital commission Strategy, business planning including the South West London Reconfiguration Programme, Better Services Better Value. Risk sharing The CCG is also in discussion with the South West London CCGs to potential work together across maternity service. Croydon CCG is currently leading discussions with 3 South East London CCGs to agree a collaborative arrangement for the management of the mental health contract with South London and Maudsley Mental Health NHS Foundation Trust. A proposal, currently be discussed with the other CCGs is set out in appendix 10. Contingency monies within the 25 per head are held to allow for contribution towards potential collaborative arrangements such as the mental health and maternity collaborations. 7

8 4. Demonstrating Capacity to Deliver The CCG is seeking its commissioning support from the South London Commissioning Support Service and an Integrated Commissioning Unit with the Local Authority. The CCG has worked with both organisations to develop the service specifications and the structures to deliver the capacity in all the areas. There is a recognition that given the new model organisations will need to be flexible with resources to ensure a full service is provided. The CSU has therefore factored a margin into their pricing to allow for this and the CCG has held contingency to allow for additional capacity if needed. The Clinical Leadership is also aligned to the CCG priorities as demonstrated in Appendix 11 Appendix 13 provides the CSU Specification (separate document) Appendix 14 provides the CSU structures (separate document) Appendix 15 provides the CCG structures (separate document) 8

9 Appendix 1: Safeguarding Governance 1. Purpose The purpose of this appendix is to: Provide a summary of the requirements that Croydon CCG need to have met in order to deliver against their core functions and statutory obligations. Set out the CCG authorisation requirements in respect of Safeguarding (Adults and Children) and highlight key points for the CCG to be aware of (based on feedback from earlier waves) Set out how the CCG will ensure its safeguarding responsibilities are achieved 2. Background The Government has reemphasised that safeguarding children remains a priority for the National Health Service. Similarly the Department of Health has published guidance for commissioners of health care which outlines the duties to ensure that appropriate recognition is made to protect adults at risk of harm and to ensure that processes are in place to support practitioners to respond to concerns. CCG safeguarding commissioning arrangements as part of the NHS reforms must therefore demonstrate a sustaining of these critical functions. Nationally identified risks with relation to safeguarding in the transition period and into the future Clinical Commissioning Groups (CCG) current level of understanding of their statutory commissioning and provider roles in relation to safeguarding vulnerable people is underdeveloped. CCGs ability to fulfil statutory functions by retaining/utilising the designated clinical specialists may be limited by the scarcity of this resource. Weakened lines of accountability due to local restructure. High profile nature of safeguarding and protection of vulnerable groups and the risks associated with deaths of vulnerable people. Requirements in relation to authorisation not reached in relation to safeguarding. 3. Guidance in respect of CCG safeguarding responsibilities The CCG recognises the statutory and non-statutory guidance which sets out the CCGs responsibilities. Appendix 1 sets out how the CCG will meet these requirements. It reflects: The functions of Clinical Commissioning Groups, DOH, June 2012 which provides an update to The Functions of GP Commissioning Consortia: A Working Document published in March 2011, to reflect the final content of the Health and Social Care Act 2012, and act as a helpful summary to which GPs and emerging CCGs can refer. 9

10 Working Together to Safeguard Children, Department for Education, June 2012 which has been updated to reflect the Changes in the Health and Social Care Act and is now out for consultation. Working Together, Statutory Guidance on Learning and Improvement (DfE, June 2012) which sets out a new approach to learning and improvement by Local Safeguarding Children Boards (LSCBs) and their partner organisations 4. CCG Safeguarding Governance Arrangements The CCG has developed over time the following principles for developing its commissioning support model: To develop a small, lean CCG employing no commissioning staff, apart from Board level appointments To ensure commissioning support has a local focus and local presence, where appropriate To maintain and develop local joint commissioning arrangements with the Local Authority To ensure the avoidance of duplication in the commissioning support provided To benefit from drawing on a central pool of skills and expertise To ensure staff have access to appropriate professional supervision and all staff have development opportunities To ensure opportunities for synergies are taken To collaborate with other CCGs on wider issues The principles have led the CCG to seek, in the first instance, all of its commissioning support from two places: South West London Commissioning Support Unit (CSU) Integrated Commissioning Unit with the Local Authority (ICU) Whilst the first principle is not to directly employ staff the interim safeguarding accountability arrangements guidance indicates that CSU was not considered appropriate for hosting safeguarding designates, also the NHS Commissioning Board did not intend for health providers nor alternative host CCG models to provide safeguarding services other than a designated doctor role. The CCG therefore will be directly employing safeguarding adult and children nurse designates. The designated doctor employment will continue through an SLA agreement with Croydon Health Services NHS Trust. The chart below demonstrates the governance structures the CCG will have in place to enable it to assure its responsibilities are carried out robustly. 10

11 Chart 1: Safeguarding Governance In the above chart: The CCG Governing Board is accountable for safeguarding. The Accountable Officer will be accountable for safeguarding The Chief Nurse on the Governing Body will have delegated responsibility for ensuring the CCG carries out its safeguarding statutory duties effectively. The Chief Nurse will act as the representative on the safeguarding boards. The GP Governing Body member will have provide GP leadership The Integrated Governance and Audit committee will have the oversight of quality including safeguarding and will be accountable to the Board. The chart below demonstrates the management structures and resources (to be confirmed) the CCG will have in place to enable it to managed its responsibilities robustly. Chart 2: Safeguarding Management 11

12 In the above chart: The Chief Nurse will provide the day to day line management and clinical professional supervision of the safeguarding team. They will also provide the safeguarding supervision for the designated professionals. Designated professional leads and named leads will be resourced to carry out the necessary duties. For the first time a designated GP lead will be appointed. Recognising the need for improving adult safeguarding and in anticipation of adult safeguarding guidance in relation to adult safeguarding becoming statutory the CCG will also resource for the first time dedicated designated adults safeguarding nurse The Designated Doctor for Children s Safeguarding and Child Death will be hosted by Croydon Health Service NHS Trust but remain accountable to the Chief Nurse. Current external clinical supervision arrangements will apply. The safeguarding team will continue to be based locally and a Croydon only focused resource 5 CCG Safeguarding Responsibilities CCG Requirement Clear line of accountability and governance within and across the organisation for safeguarding and commissioning of services Board level lead in place to take senior leadership responsibility for organisations safeguarding arrangements Roles and functions in place to ensure robust safeguarding standards in place across commissioning and provider services Systems in place for cooperating with LA and partners to improve the wellbeing of children in the LA area Robust links with Quality and Patient Safety CCG Response CCG Governing Body accountable through the Accountable Officer Chief Nurse has the delegated responsibility for ensuring the CCG carries out its safeguarding statutory duties effectively. Integrated Governance and Audit committee will have the oversight of quality including safeguarding and will be accountable to the Board. The Chief Nurse will act as the representative for safeguarding on the local safeguarding boards. As above Integrated Governance and Audit will hold accountability for safeguarding Chief Nurse will hold delegated Board accountability Safeguarding Governance Group in place with oversight of commissioning assurance. Safeguarding roles and functions well described across commissioning and provider Strengthened safeguarding team (new children s named GP post and adult safeguarding nurse designate) Accountable Officer is a member of the HWBB Chief Nurse membership on the safeguarding boards and partnership boards. Chief Nurse and Director of Governance and Quality 12

13 CCG Requirement Core designated roles for safeguarding children in place as set out in Working Together and CCG Functions guidance Key roles/functions in place to ensure capacity and capability to meet statutory safeguarding duties, including the need to safeguard and promote the welfare of children,, requirements around employing staff and being a member of the LSCB Adult safeguarding lead arrangements in place To act compatibly with the European convention on Human Rights Roles in place to ensure participation in the development and implementation of crime and disorder strategies and youth justice services Systems in place for participating in Domestic Homicide Reviews Systems in place for discharging duties under the Mental Health Act Arrangements in place to share relevant information Systems in place for the provision of supervision and CCG Response Service Spec with CSU includes the integrated governance team to work with the safeguarding team Integrated Governance and Audit Committee Senior Management All roles and functions inplace. A clear line of accountability and reporting back to the Chief Nurse A safeguarding team structure: Children s Safeguarding Designate Nurse and Head of Adult Safeguarding Designated nurse for safeguarding Designated adults safeguarding lead new role Designated Dr Safeguarding and child death. Clear SLA in place with provider for Designated LAC roles. Safer recruitment forms part of the functions within the designated roles. Chief Nurse will fulfil Board responsibility and represent the CCG on the LSCB Adults Safeguarding Designate Nurse - New post identified Delivering on core functions relating to statutes that relate to safeguarding, patient quality and safety, set out in JD. Delivering on Safeguarding and commissioning input into the local crime and disorder strategies and youth justice services, set out in JD. Adults safeguarding lead will provide expert health input into DHR s Adults safeguarding lead role have oversight of the management of duties in respect of MHA. Delivering on core functions in relation to information governance (information sharing protocols). IG roles described within the CSU structure Chief Nurse will provide safeguarding supervision for designated professionals. 13

14 CCG Requirement support for staff, including safeguarding training Systems in place for ensuring sufficient capacity and capability for participating in and leading on investigations and Serious Case Reviews CCGs have secured the expertise of consultant paediatricians whose designated responsibilities are to provide advice on commissioning paediatrics services with expertise in undertaking enquiries into unexpected deaths in childhood SLA in place for securing the role of a Designated Paediatrician for unexpected deaths and discharging responsibilities as set out in Working Together CCG has systems in place for training staff in recognising and reporting safeguarding issues CCG has secured the expertise of a designated dr and nurse for Looked After Children CCG Response SCR processes described within the designated roles across children s and adults safeguarding. Clear lines of accountability to IG&A Committee through the Senior Management Team. The Designated Doctor for Children s Safeguarding and Child Death will be hosted by Croydon Health Services NHS Trust but remain accountable to the Chief Nurse. Current external clinical supervision arrangements will apply. SLA in place Safeguarding planning and delivery of training included in JDs Training programme in place for all Independent Contractors and commissioning staff (96% of GPs already trained). Training programme for Governing Board members to be completed by 1 st April 2013, and updated annually. The Designated Doctor for Children s Safeguarding and Child Death and the designated nurse for LAC will be hosted by Croydon Health Services NHS Trust but remain accountable to the Chief Nurse. Current external clinical supervision arrangements will apply. 14

15 Appendix 2: Recovery Governance 1. The Croydon financial recovery will span at least three financial years (2011/ /14) and covers a range of recovery activities and bridges a number of organisations, all against a shifting backdrop in the commissioner landscape. This paper sets out a framework through which the governance and oversight of the various planks of the recovery plan will be achieved in order to maximise the chances of successful delivery. From the 1 October 2012 full shadow operating arrangements will be place for CCG Commissioning, although accountability will still remain with the PCT Joint Board. 2. Governance arrangements The following diagram shows the meeting structure which will support the governance of the recovery programme with the ultimate aim of assuring the SWL joint boards and Croydon CCG Board of the delivery of the NHS Croydon recovery programme. SWL PCTs Joint Boards Croydon CCG Board Strategic Transformation Board SWL Joint Finance Committee Croydon Challenged Trust Board Croydon CCG Management Team (Incl dedicated Recovery Agenda) QIPP Op s Board (weekly) Acute Task Group (monthly in QOB) The shaded boxes show the meetings which will have non executive attendance. All of the above meetings are expected to have clinical commissioner attendance as a routine, with the exception of the joint boards, finance committee, and the acute task group. The dotted lines in the above diagram indicate lines of reporting for information only to avoid duplication. The meetings will be chaired as follows, with terms of reference attached: 15

16 Joint boards SWL Chair Frequency Terms of Reference Joint Finance committee Non-Executive Chair Monthly Croydon CCG Board/ Delegation committee Croydon Challenge Trust Board (previously known as Croydon Recovery Board) Strategic Transformation Board (formerly Strategic Sponsorship Group) Croydon Senior Management Team Recovery Task Group (Dedicated Meeting of Croydon SMT) CCG Chairs SWL Director of Finance Monthly Monthly App 1 To be agreed Monthly App 2 Borough Director Borough Director Managing Managing Weekly (except last week of the month) (i) Acute Recovery Action (weekly) (ii) Monthly reporting (3 rd week) QIPP Operations Board (QOB) Acute Task Group GP Clinical Leader (Chief Finance Officer) GP Clinical Leader (Chief Finance Officer) Weekly App 3,4,5 Monthly (3 rd week of QOB) App 6 Croydon Challenge Trust Board will convene monthly to receive reports on each aspect of the recovery plan. Monitoring of delivery against the recovery plan will be supported jointly by the cluster PMO and the borough QIPP team. A key part of the Croydon recovery plan will be the impact of the integration agenda across health and social care. This agenda will be driven by the Strategic Transformation Board, and will be supported by a series of task and finish groups which will focus on specific areas of integration. The first two such groups are likely to be frail elderly and children and young people. The Croydon Senior Management Team will receive full finance, QIPP and SLA reports on the third meeting each month. Issues outside this time can be escalated at the normal Senior Management Team meetings. The QIPP Operations Board (QOB) will oversee the QIPP programme including all demand management and referral management plans. This group will be supported by the borough QIPP team. QIPP schemes will be brought to the meeting on a 16

17 rolling basis, with RED schemes being recalled fortnightly, Amber schemes four weekly and Green schemes six weekly. The QOB will be chaired by one of the Clinical Leaders supported by the CFO. The focus of discussions is on delivery against metrics and agreed actions. QOB action records and meeting schedules will be reported to SMT on a monthly basis. The Acute Task Group will meet on the third week of each month as the first hour of the weekly QOB meeting. Its purpose is to look specifically at the management of the acute portfolio, looking at the delivery of the KPI benefit and other contractual levers, the overall financial performance against contract and the triangulation of QIPP and acute financial performance. This group will be supported by the ACU, with input from the borough QIPP team. The group needs to cover the breadth of acute providers and issues, as well as focus on Croydon University Hospital. The success of the recovery programme is highly dependent on the relationship with the main acute provider, which is now also the provider of community services in Croydon and therefore also key to the integration agenda. The following structure shows how the existing contract management arrangements will be augmented in order to: Ensure that the acute and community contract is complied with Ensure that the KPIs deliver as expected Triangulate the QIPP and acute financial performance Ensure that CUH delivers its part in the PCT s QIPP plans Ensure that the PCT plays its part in CUH s CIPs plans Clinical commissioner attendance is expected at CQRG meetings as routine and at contract meetings as required. 3. Delivering the financial recovery The following diagram describes how the various strands of the recovery plan will be overseen from an operational perspective: Accountable Officer (Designate) Borough Managing Director Director of Commissioning Chief Finance Officer (Finance and Recovery) Commissioning Managers (QIPP leads) Head of Programme Office Data analyst (to be appointed by CSU) Programme Office Support Delivery of the financial recovery will be managed and delegated per the diagram above 17

18 The Chief Finance Officer has dual responsibility for financial management and recovery to ensure QIPP delivers cash releasing savings to the CCG s financial position. The Programme Management Office has key role to support delivery through (i) implementing tight performance management process from PIDs to monthly reporting (ii) ensure projects are based on clear metrics and (iii) support project managers to unblock challenges to delivery. Project Managers have clear and unequivocal responsibility for delivering against clear project metrics through specific agreed actions to deliver change and savings. The delivery team for each QIPP project is comprised of the following members: Senior Management Team Lead Commissioning/Project Lead GP Clinical Leader Finance Informatics Public Health Practice Nurse Lead 4. QIPP Project Initiation Procedures (Extract) A carefully designed project is more likely to succeed. That is not to say that the project manager can foresee all future risks, or that the project plan once agreed cannot change; it almost certainly will. However time invested in justifying the business case, identifying the risks to delivery, establishing the detailed implementation plan and identifying the key milestones and when services are likely to be available, or savings are likely to materialise, will substantially increase the chance of the project delivering its objectives. Justifying the business case. Use the Executive Summary in the PMO Workbook template (on T:\Localities\Project_Mangement_Office\Templates\PMO) to establish your business case for the project. The template is fairly self-explanatory, but the PMO is there to assist you in its completion; Use the Risk Register to start identifying your risks, how significant they are, and the proposed strategy for mitigation; Use the Milestone Tracker to devise the detailed implementation plan for your project identifying the key stages, and the tasks you need to complete each week/month and who will complete them to achieve each key stage. Make sure that you include any risk mitigation strategies identified in the risk log as part of your project plan, and make sure you include liaison with Commissioning and Finance as key stages in your project so that the benefit or costs of your project can be fed back into commissioning and budgeting. Use the Monitoring Spreadsheet to identify and profile the savings and costs as they are expected to materialise month by month. Maintain contact with the PMO throughout they re here to assist you to justify, plan and implement your project. When your project is ready, submit it to the QIPP Operational Board (QOB) for validation (the QOB is held every Thursday). Following approval at QOB, the project will then be submitted for agreement at the Recovery SMT, which is held on the third Tuesday of each month. PMO Meetings Once your project is approved, you will meet on a monthly basis with the PMO to discuss the progress of your project, the risks you ve identified, any issues that are 18

19 emerging and any milestones or tasks achieved. The PMO will then put this information into a summary report which is discussed at the Recovery SMT on the third Thursday of each month. Each month you should update your self assessment reporting your Risk Register, the Milestone Tracker and the Monitoring Spreadsheet with any changes in cost savings achieved, issues raised etc. Changing Your Project It is the nature of projects that they are based on assumptions and planned ahead of time. Once in development, issues arise that need to be addressed, or the original assumptions that underpinned the project may have changed and thus the project plan itself needs to be changed. However changing a project without considering the wider implications of such a change is best avoided; particularly as the project has been approved by senior management to reach certain goals using defined resources and that many issues can be overcome without project redesign. Therefore it is usual that, before making a significant change to a project that the proposed changes are discussed with the PMO, a change control form is completed and then reviewed and signed off by your Project Sponsor. 19

20 1 Purpose CROYDON CHALLENGED TRUST BOARD (SWL LONDON ACCOUNTABILITY MEETING) DRAFT TERMS OF REFERENCE September 2012 to March 2013 The objective of the CHALLENGED TRUST BOARD / ACCOUNTABILITY meeting is to support the Clinical Commissioning Group s (CCG) preparation for authorisation and transition to take on accountability for performance, quality and safety and finance, with particular emphasis: To ensure the financial recovery of NHS Croydon To ensure the delivery of the QIPP plans To monitor performance against the operating plan The meetings will also provide an opportunity to test how the assurance and accountability arrangements will work in practice between the CCG s and the National Commissioning Board (NCB). 2 Objectives of the Meetings The meetings will consist of two parts, Part A & Part B, and the overall objective for both parts is to review Performance, Quality and Patient Safety and Finance. Reporting will be done by exception, focusing on areas of concern and the remedial plans. For part A of the meeting, the Cluster will assume the role of shadow NCB and seek assurance from the CCG s that they are delivering against an agreed set of performance, measures, quality and safety standards and achieving a balanced budget, with particular emphasis: To ensure that the conditions imposed on NHS Croydon by DH or NHS London are complied with To monitor the financial position of NHS Croydon and ensure that the borough team identifies any areas of financial pressure as they arise and take corrective measures to address the issue To monitor the delivery of the QIPP plan and ensure that the borough team identifies any shortfalls as they arise and take corrective measures to address the issue To monitor the performance of Croydon against the operating plan, to ensure that for any areas where performance is below target that mitigating action plans are put in place to address the issue. To provide a forum through which cross cluster issues such as with primary care or acute contracts can be escalated Part B of the meeting will focus on the statutory responsibilities that will 20

21 transfer to other receiving organisations. The Accountable Officer will take on the Borough Managing Director responsibility. This part of the meeting will be reviewed when the accountability arrangements for Public Health and National Commissioning Board become clearer. 3 Membership Core Members Cluster Director of Finance (Chair) CCG Accountable Officer/Managing Director CCG Chief Financial Officer Cluster Director of Performance Cluster Director of Nursing Cluster Medical Director PCT Non Executive Director In Attendance: Cluster Business Manager for Finance Admin support Cluster PA CCG Director of Performance and Governance Local Authority Representative Public Health Representative Borough Representative CCG AO to decide other appropriate person/s to attend depending on the agenda items. In Attendance as and when required: CCG Chair Primary Care Representative Acute Contracting Unit Representative Clinical Support Services Representative Clinical Quality Review Group Chair 4 Quorum The quorum will be a third of the membership with a minimum of the Chair Person, CCG Accountable Officer and Borough Representative. 5 Frequency of Meetings Meetings will be held monthly. A request for agenda items will be sent out two weeks before the meeting and the agenda and supporting papers will be circulated to members a week before the meeting. 21

22 The Cluster will provide the latest months Performance reports and Quality & Patient Safety reports. The CCG CFO will provide the latest finance reports. 6 Accountability During the shadow year SWL Cluster will continue to hold statutory responsibility for commissioning of services and shall need to maintain overview to ensure that these are being discharged. Minutes from the meetings shall be made available to the Performance, Finance and Audit Committees and the Clinical and Integrated Governance Committee. 7 Inception of group and review of responsibilities Date of review August 2012 Date of next planned review January

23 Appendix 3: Statement of Intent: Working with the SWL Primary Care Team in Preparation for Working with the NHS Commissioning Board June 2012 This statement of intent describes how Croydon Clinical Commissioning Group will work in partnership with the SWL Cluster Primary Care Contracting team as part of preparing for future work with the NHS Commissioning Board (NHSCB) to integrate commissioning where appropriate and improve quality of primary care, and particularly to take account of need and unexpressed demand. This statement of intent relates to the financial year 2012/13 and will be superseded once NHSCB policy describing the working relationship between NHSCB and CCGs is published. From April 2013 and probably in shadow form from October 2012 the NHS Commissioning Board will commission and manage all contracts related to the provision of Primary Medical Services (GMS, PMS, APMS) under the NHS Act 2006, as amended by the Health and Social Care Act GPs as signatories to Primary Medical Services contracts are entitled to membership of their local Clinical Commissioning Group and as signatories to these contracts GPs are responsible and accountable for delivery under the terms of the contract. They are also required to provide a suitable practice i.e. the place where treatment is provide under their contract. The NHSCB will plan local primary care services in the context of CCGs commissioning strategies, health and wellbeing strategies, the Joint Strategic Needs Assessment and the Pharmaceutical Needs Assessment. Patients, Carers and Local communities will have a stronger voice to influence and challenge how health and social care services are provided. From April 2013 the NHSCB will have statutory responsibility for commissioning primary care services, but CCGs will have a statutory duty to assist and support the NHSCB in securing continuous improvement in the quality of primary medical services in partnership with their member practices. The Towards Establishment guidance sets out how each practice has to appoint an individual to act on its behalf in dealings with the CCG. The intention is that the regulations will require that this person has to be a GP or other healthcare professional. The SWL Cluster Primary Care contracting team is currently responsible for Commissioning Primary Medical Services and performance management of primary care. The improvement of primary care sits somewhere between the Cluster team and the CCGs. The current primary care contracting arrangements are a good proxy for the future work that the NHS Commissioning Board will undertake in partnership with CCGs in relation to primary care improvement, GP outcome standards and primary care improvement within the context of service re-design as well as meeting the needs of local and registered populations. It is known that under the CB s intended single operating model (yet to be published), CCGs will be responsible for the improvement of primary care and that the performance management of such will be delivered by one standardised approach that will include dialogue between NHSCB and the local CCG. CCGs will have a critical role in providing clinical leadership to deliver high quality, responsive and safe services for patients. 23

24 As described in Developing clinical commissioning groups towards authorisation, CCGs are dependent on the unique role of general practice in connecting and acting as the intermediary for all the care patients receive. Practices are central to the new commissioning arrangements as well as providing primary medical services. As providers of care, GP practices take commissioning decisions daily with each referral and prescription. CCGs will work with their member practices to ensure these micro decisions are clinically appropriate and deliver best outcomes for patients. While intelligence about these commissioning decisions is of primary concern to CCGs, it is also critical for the NHSCB to review the performance of individual practices. CCGs are best placed to support quality improvement in primary medical care, where necessary in partnership and with the support of the NHSCB. The NHSCB will be solely responsible for contract compliance, and therefore CCG member practices will be able to focus on local priorities and supporting continuous development. CCGs, working with the NHSCB, will take a quality improvement approach based on: Evidence of engagement and involvement with patients and the public Benchmarking across member practices of healthcare needs indicators, interventions, and patient outcomes Commitments to openness about data and mechanisms to enable information sharing Clear approaches to peer review and discussions across member practices Self assessment of need, intentions and anticipated impact There is a strong link between CCGs clear and credible QIPP plans and in particular their role to reduce unwarranted variation and tackle inequalities, and the ambition of the operating model for primary care. Until April 2013 or and until the Commissioning Board intentions are published, the 6 South West London CCGs have made a commitment to undertake the following work with the SWL Cluster primary care contracting team: 1. To develop arrangements and mechanisms for working in partnership to improve quality of primary care and in particular to take account of need and unexpressed demand. 2. To identifying local gaps in service and where possible take advantage of section 106 planning gain 3. To integrate primary care improvement in line with the pharmaceutical needs assessment and the wider joint strategic needs assessment 4. To draw together the wider intelligence gained from equality impact assessments related to the CCG commissioning activity and intentions. 5. To support ongoing needs assessment, planning related to primary care enhanced service provision 6. To support the further development and roll out of the Londonwide GP Outcome Standards framework. 7. To lead the engagement of member practice and the set up of agreements and processes for performance management based on the GP outcome standards framework with immediate effect. 8. To facilitate the interface and day to day exchange with GP practices in relation to the GP outcomes standards. 24

25 9. To work within the current performance management framework and committee structure 10. To discharge professional responsibilities in relation to reporting unprofessional or poor practice to the primary care contracting team and regulatory bodies where appropriate. 11. To produce regular reports on primary care improvement for the CCG and cluster integrated governance committees as considered necessary to ensure delivery of safe services. 12. To work as a partner with the Primary Care Contracting Team to integrate commissioning where appropriate and offer advice on the following commission functions that in future will be commissioned by the NHSCB: Pharmacy Dental NHS sight tests Specialised services (through specialised commissioning arrgts) Prison health services / custody Some services for armed forces Public health services for 0-5s Imms & screening programme Public health for those in prison / custody Sexual assault referral services Child health info systems This statement of intent is in keeping with the CCG constitution and the commitment to work in partnership with the NHS Commissioning board to integrate commissioning where appropriate as part of discharging the CCG statutory duties. 25

26 Appendix 4: Statement of Intent for Collaboration between CCGs and Specialised Commissioning Introduction The London Specialised Commissioning Group is pleased to continue the conversation between the SCG and CCGs following the presentation to the SW Pathfinders group on the 15 th March. Specialised services will be commissioned by the NHS Commissioning Board (NHS CB) from April 2013 and probably in shadow form from October This makes specialised services a good proxy for the sort of joint commissioning around care pathways from primary through to tertiary services, which will need to be managed in the future. There are a number of issues outlined below which will need to be carefully managed to prevent gaps in care or additional costs arising, and to maximise the opportunities of clinically led commissioning. In the short term the commissioning round for 2013/14 needs to be managed to ensure that normal commissioning initiatives continue, where there is joint commissioning from the same provider, and the residual specialised services still in Clusters are safely transferred to the NHS CB. This statement of intent may be superseded by national / NHS CB directives. General description of current commissioning of specialised services and how this works with PCTs Specialised services are generally those with a planning population of a million, are low volume, have a high cost of treatment and rapid changes in technology. Commissioning specialised services is carried out on a larger scale than PCTs because of both the opportunity to create more coherent patterns of service for rare conditions, but also to minimise risk to PCT budgets of large and inconsistent swings in activity and expenditure. The national definition set for specialised services consists of 38 service definitions (SSNDS). Each definition may have more than one service element in it. The services in the definition set are diverse, stretching from rare childhood cancers to high secure mental health services for adults detained by the criminal justice system. Specialised services are characterised by the restricted number of providers able to provide services. The Specialised Commissioning Group (SCG) is a joint committee of the 31 London PCTs, commissioning a range of services to the value of 966m in 2012/13 of which 841m comes from London PCTs. During the year an additional range of specialised services will be transferring from PCT Clusters to the SCG, as part of the transition towards the NHS CB. This will leave a final tranche of services to be transferred by April In previous years PCT/Cluster commissioners, have worked closely with the SCG during the contracting of services, since they commission from the same providers. This close alignment allows a shared commissioning approach to providers, a shared approach to QIPP initiatives and prevents commissioning decisions contradicting each other. The lead commissioner has previously always been the Cluster since specialised services have been a smaller part of the provider income. From April 2013 the lead for some providers will potentially be the NHS CB since specialised services will supply the majority of the trust income. 26

27 How will specialised commissioning work from April 2013? Specialised services are one of the four groups of services to be directly commissioned by the NHS CB. The operating model for how this will be carried out is not yet clear and potentially could include the use of one, or all three, London Commissioning Support Services. The national work on specialised commissioning intends there to be common specifications, quality markers and outcome measures for specialised services. London clinicians and commissioners are fully involved in the development of the national guidelines. The relationship between specialised and non specialised services in the new system will include joint commissioning from common providers, invoice validation and claims management and joint QIPP initiatives. There may be providers in the future where the lead commissioner is the NHS CB because specialised services form the largest component of income for the provider. This will require specialised commissioners to monitor KPIs for the provider and report to CCGs, reversing the usual communication flows. General principles and aims for joint commissioning between CCGs and the NHS CB -Patient centred commissioning -Clinical leadership and shared vision -Effective partnership working across pathways of care -Sound governance, accountability and finance -Development of incentives and shared benefits -The value of benchmarked information and contracting mechanisms -Responsiveness to the need and requirements of CCGs Issues to be resolved in the new system between CCGs and specialised commissioning How is the 2013/14 commissioning round to be organised to prevent costs rising, present a unified approach to providers and commission new and exacting national specifications which have implications for primary and secondary services? How do we manage a safe transfer of commissioning between PCTs (and shadow CCGs) and the NHS CB? This is both a consequence of being able to accurately define specialised from non-specialised workload to ensure the correct activity and finance is identified and then monitoring the system to ensure that work is accurately coded and invoiced by providers. How do CCGs organise care for the group of patients who move between tertiary services and primary and secondary care? How do we prevent patients requiring tertiary care? Managing the transfer of remaining specialised services to the NHS CB from April 2013 The SCG commissioned approximately 50% of the total amount of London specialised services in 2011/12. This will rise in 2012/13 as an agreed range of further services (the minimum take ) such as cardiac surgery are transferred to the SCG following contract negotiations by PCT Clusters and before contracts are signed. This leaves a residual but substantial number of services still to be transferred before the start of the NHS CB in April These remaining services 27

28 are generally more complicated to identify, to code and to count. The national work to clearly identify the complete range of services to go into the NHS CB is not yet complete. Once this is complete then the SCG will need to work closely with CCGs, clusters and providers to identify activity, finances and quality initiatives to transfer. This needs to be carried out in a very structured way to avoid significant risk. Managing the 2013/14 commissioning round The transfers will add complexity to the 2013/14 commissioning round, compounded by the number of new organisations who will be conducting the round for the first time. Previous close working in the London health system will need to be recreated to conduct the round. Since providers are under financial pressure to maximise income, commissioners need to be highly co-ordinated to avoid costs increasing. Working together up to April This statement of intent is to set out a process and plan to work together over the course of the next nine months to manage these changes effectively. The key contact in the SCG will be Alex Berry, Divisional Director for South London who carries the responsibility for the commissioning round. Key contacts for Kingston and Wandsworth CCGs will be the two commissioning and clinical leads. A first meeting is planned for early July. This will allow the CCGs to effect a safe handover, set up systems and processes for effective joint working and manage risk across the system. Once the immediate issues have been successfully managed then a more strategic piece of work about collaboration over care pathways is planned. Specialised commissioning represents about 10% of NHS expenditure, and affects the lives of a highly vulnerable population of patients. Effecting a smooth transition to the new NHS system will manage risk for both patients and NHS organisations. 28

29 Appendix 5: Croydon Clinical Group The Commissioning Model This paper was agreed by the CCG Governing Body at its September meeting. At that point, the assumption was that one of the options (Option 2) would involve the health staff of the Integrated Commissioning Unit being employed by the Commissioning Support Unit (CSU). The CCG has now agreed to directly employ the ICU and Safeguarding staff. This followed a review after the publication of interim safeguarding accountability arrangements guidance which indicated that a CSU was not considered appropriate for hosting safeguarding designates. Since the posts themselves remain unchanged, and the degree of integration with the Local Authority over time remains unchanged, there have been no material changes to the scoring given in the option appraisal undertaken in September. It is the current proposals that are presented here. 1. Introduction This appendix paper sets out the Croydon Clinical Commissioning Groups (CCG) approach to sourcing its commissioning support. It sets out the principles and the model currently under development and the value for money analysis of the proposed model. 2. The National Context The foundation of the reformed NHS is based on devolution of power and responsibility for commissioning to Clinical Commissioning Groups (CCGs), shifting decision making as close as possible to local patients. Equity and Excellence: Liberating the NHS said that CCGs will have the freedom to decide how to carry out their commissioning functions and what support they use to help them. It also made clear that the new commissioning system needed to be better and more efficient than anything that has gone before. A very clear picture has emerged nationally that CCGs are not reinventions of PCTs, that they are local clinically focused organisations who will not have the resources to do all aspects of commissioning themselves. The NHS Commissioning Board Authority has indicated that the fairest approach to calculating the 25 per head running costs allowances for CCGs is to base them on the GP registered lists for practices within the CCG but moderated at local authority level to match the Office for National Statistics (ONS) population projections. This ensures that the aggregate population figures match the ONS estimate of the England population, and helps take account of the unregistered population. The 25 per head would need to cover: Allowances and levies CCG Board costs Clinical engagement Accommodation Commissioning Outside of the 25 per head are programme costs, the clinical functions to support the commissioning role. 3. The Croydon Commissioning Model The CCG Board is clear of the principles upon which it will seek its commissioning support. 29

30 In the context of the 25 per head allocation, the CCG recognises that it cannot afford to directly provide all of the commissioning functions itself. It proposes to commission/procure its commissioning support from elsewhere. The CCG has developed over time the following principles for developing its commissioning support model: To develop a small, lean CCG employing no commissioning staff, apart from Governing Body level appointments To ensure commissioning support has a local focus and local presence, where appropriate To benefit from drawing on a central pool of skills and experience To maintain and develop local joint commissioning arrangements with the Local Authority To ensure avoidance of duplication in the commissioning support provided To ensure staff have access to appropriate professional supervision and all staff have development opportunities To ensure opportunities for synergies are taken To collaborate with other CCGs on wider issues The CCG has three options for securing commissioning support: Option 1: Option 2: Option 3: Provide all commissioning support from within CCG Procure end-to-end commissioning support from a Commissioning Support Unit (with Joint Commissioning Unit either integrated with Local Authority with health staff employed by the CCG until integration is achieved) Mixed Support: Procure Core Services from Commissioning Support Unit, and provide most other commissioning support services directly from CCG and Joint Commissioning Unit. Based on a financial and a non-financial assessment of the options, summarised in section 5 the CCG is seeking, in the first instance, all of its commissioning support from two places: South West London Commissioning Support Service (CSS), which has passed the BDU authorisation check point 2. Integrated Commissioning Unit with the Local Authority (ICU) including health commissioning, strategy, service re-design and safeguarding. CCG has allowed within its contingency to, funding to secure capacity to undertake a market assessment and procurement of commission support for the future. 3.1 South West London Commissioning Support Service The CCG is seeking to buy an end to end service which includes: The Core Package Enhanced services o ICT for Primary Care o Governance o Bespoke reporting and advanced analytics o Community Contract Management o Informatics tools for CCGs and GPs o Continuing Care o Medicines Management Additional services for Croydon 30

31 o o LES/DES contracting PPI Services offered by the CSU, which the CCG will not be purchasing and will be part of the Integrated Commissioning Unit are: PMO and QIPP /Service Redesign The CCG recognise that it is important to ensure QIPP and service redesign is part of the commissioners day job and therefore will source this form the Joint Commissioning Unit. The CSU were not able to offer a PMO offer on its own and therefore the CCG will also need to source this from the Joint Commissioning Unit Mental Health Contracting Mental Health commissioning is currently jointly commissioned with the LA and there are significant synergies to continue to do this. However discussions are starting with South East London CCG s with regard to have a mental health collaborative approach for the SLAM contract. Strategic Planning and Business Planning The CCG recognises that a significant amount of planning needs to be done collaboratively with the LA and is therefore seeking this function as part of the Joint Commissioning Unit. 3.2 Croydon Integrated Commissioning Unit The CCG fully recognises benefits of building on the joint commissioning arrangements in place. Its vision is to have a fully integrated commissioning unit to support the commissioning and delivery of integrated care in Croydon. To develop the model with sufficient engagement, to consult with staff and to implement the model, will take a maximum of up to 18 months. In the first instance therefore the Integrated Commissioning Unit will look to co-locate health and Local Authority commissioning staff together. The CCG require an integrated Commissioning Unit that commissions for both adults and children, and for both physical and mental health. The health staff will be employed by the CCG and be managed by the lead CCG director (Director of Finance for the PMO function, the Chief Nurse for safeguarding functions, and the Director of Commissioning for all other functions). The health commissioning functions, in the first instance, to be co-located in the Integrated Commissioning Unit are the commissioning and service redesign for: Long Term Conditions Older People End of Life Children s and Maternity Planned Care Mental Health Learning Disabilities PMO Safeguarding Some CSU functions will be co-located within the Integrated Commissioning Unit, to ensure effective management of the commissioning agenda. The future model of the Integrated Commissioning Unit will begin to be explored in the next few months, and it will be open to exploring the commissioning market more broadly. 4 Value for Money 31

32 As described in section 3 the CCG has three options for securing commissioning support: Option 1: Option 2: Option 3: Provide all commissioning support from within CCG Procure end-to-end commissioning support from a Commissioning Support Unit (with Joint Commissioning Unit either integrated with Local Authority or with health staff employed by the CCG until integration is achieved) Mixed Support: Procure Core Services from Commissioning Support Unit, and provide most other commissioning support services directly from CCG and Joint Commissioning Unit. 4.1 Non Financial Assessment In principle, the preferred model in principle for Croydon CCG has for some time been Option 2 (End-to-End CSU). It should be noted that the other SWL CCGs are currently largely pursuing Option 3 (Mixed Support), although purchasing some CSU enhanced services as well. Under the SWL CCG collaboration agreement there are some areas of SWL CCG collaborative commissioning that will be provided/hosted by CCGs. These are important but small areas covering strategy, mental health and potentially maternity. The relative advantages to the CCG of the Option 2 (End-to-End CSU) outweigh those of the other options, subject to affordability and value for money. Scale of 1-5 (1=low, 5=high) A small, lean CCG employing no commissioning staff, apart from Board level appointments, transferring employment risk (incl performance) Supports the domains for authorisation demonstrating operating at scale for commissioning support Commissioning support has a local focus and local presence, including maintaining and developing local joint commissioning arrangements with the Local Authority No duplication in the commissioning support provided Staff have access to appropriate professional supervision and all staff have development opportunities Option 1 CCG Directly Provided Option 2 CSU End-to- End and JCU Option 3 Mixed Support Ensure opportunities for synergies are taken TOTAL (out of 30) NON-FINANCAL CONCLUSION NOT PREFER VIABLE RED VIABLE Proposed Commissioning Support and Running Costs for Croydon CCG (Option 2: End to End) 32

33 Based on adjusted population of 352,400 (practice population scaled to ONS population projections), Croydon CCG has an 8.81m ( 25/head) maximum to spend on running costs in 2013/14, per the 2012/13 Operating Plan guidance. The table below summarized the proposed commissioning support and running costs for Croydon CCG. It is based on 2012/13 pay rates and allows for 1% inflation in 2013/14. Description CCG/Hosted 000s /head Staffing (WTE) Board Costs (incl Audit/Annual Report) 4.0 1, Clinical Engagement (incl Clinical Leaders) Clinical Engagement (contingency) CCG and JCU Non Pay/Accommodation CSU Core Services 2, CSU Enhanced Services 1, CSU Hosted Joint Commissioning Unit (health only) CCG Collaboration (MH, Strategy, Maternity) Contingency Total Running Costs , Prescribing 1, Safeguarding Primary Care Development Continuing Care Nurse Assessment Total Commissioning Support 11, Primary Care IT (funded from NCB) Total Croydon CCG 12, The 2.84 ( 1.0m) contingency is analysed as follows: 0.51 ( 0.2m) contingency for children s and informatics resources 1.10 ( 0.4m) contingency for inflation, levies, third party liability scheme ( 0.4m) general contingency (including any legal advice on commissioning). 4.2 Financial Assessment The financial assessment of the preferred option focuses on the following metrics: a. Affordability with 25/head running cost target (ie level of contingency) b. Affordability of total commissioning support (incl clinical exclusions) with anticipated CCG resources c. Value for money i. Against benchmark Commissioning Support Services ii. Analysis of SWL CSU Costing and Pricing Model iii. Benefit of reinvestment of CSU surplus/contingency Financial Analysis of Options 33

34 Option 1 is not considered in the financial assessment as it is not viable on non-financial grounds. Option 2 (End-to-End) is evaluated in the first instance. Option 3 (Mixed Support) is considered in the context of key areas of difference from Option 2 (End-to-End) For scoring purposes, the lowest cost option is awarded 30/30 (Option 3) and then all other options are scored lower in proportion to the % excess cost (ie Option 3 scores 3% less than Option 2 = 29). 5.3 Financial Appraisal of Option 2 (End-to-End) The financial appraisal below does not provide the detail of the financial appraisal as this is commercial in confidence. Affordability with 25/head running cost The proposed running costs are well within the 8.81m 25/head target with specific and general contingencies to manage operational and definitional risk. The contingencies total 1.0m ( 2.84/head.) The CCG is able to achieve economies on fixed board costs across the larger population base to reinvest in clinical engagement, commissioning support and joint commissioning unit. It should be noted that employment risk (leave, performance, redundancy, business continuity) is borne by the SWL Commissioning Support Unit for the core and enhanced commissioning support services. Such risk on the health resources in the Joint Commissioning Unit remains with the CCG. Affordability within total CCG resources Based on the July 2012 Baseline Mapping exercise, the total cost to the CCG of commissioning support ( 11.4m) is lower than the mapped equivalent resources from the PCT ( 12.0m). This is a favourable position but is subject to the final mapping resources to new organisations. There are some risks to be noted in this initial analysis and conclusion: The specific allocations to CCGs are still not known. The specific mechanism for allocating 25/head running costs is not known The allocation from NHS CB Primary Care resources to the CCG for primary care IT is not known The financial challenge for 2013/14 is significant. Benchmarks for Commissioning Support Services At this stage in the development of Commissioning Support Services across England, it is very difficult to draw comparisons. All CSUs have been working towards submitting the Final Business Plans as part of Checkpoint 3 on 31 August CSUs, including SWL CSU have largely focused on delivering support to local CCGs. It is expected that after Checkpoint 3 there will be the opportunity to see the relative competitiveness of CSUs prior to finalising prices and signing SLAs in October

35 It has been possible to benchmark unit prices for the SWL CSU core services across the 12 CCGS in South London. Croydon CCG benefits from one of the lowest prices per head due to the size of its population. Analysis of SWL CSU Costing and Pricing Model The SWL CSU has established a cost plus model for pricing its services. The costing model allows for a number of risks that are effectively transferred from the CCG to the CSU. Three service types (core, enhanced, and hosted) differential costing and pricing assumptions have been applied. It should be noted that there is a recognition in the enhanced pricing that Croydon CCG is purchasing end-to-end and in the hosted pricing there is no margin as there is not risk transfer. The pricing and costing principles have been negotiated with the CSU since November 2011 to get to a position that balances CSU risk and CCG affordability. SWL CSU Reinvestment of Contingency/Surplus It is important to note that for at least the first three years, the SWL CSU will be part of the NHS Commissioning Board and is expected to, and is planning to, reinvest unutilized contingency/surplus into improving service quality for its foundation customers. As the largest foundation customer, Croydon CCG will have a significant input in prioritising and benefiting from the areas of improvement. 5.4 Financial Assessment: Option 3 (Mixed Support) The key cost/price differential between Option 2 (End to End) and Option 3 (Mixed support) are the costing/pricing assumptions on the following services: Enhanced Services Prescribing Safeguarding Primary Care Development Continuing Care Assessment If these were employed and managed directly by the CCG, the cost would be lower. There would be a cost reduction. There would also be some potential to manage non-pay costs more flexibly locally. The relative advantages/disadvantages of managing employment risk locally is dealt with in the non-financial appraisal. 5.6 Conclusion The appraisal can be summarised as follows: Ranking (1 =low, 3 = high/preferred) 35 Option 1 CCG Directly Provided Option 2 CSU End-to- End and ICU Option 3 Mixed Support NON FINANCIAL APPRAISAL (/30) FINANCIAL APPRAISAL (/30) N/A 29 30

36 (most affordable =30) TOTAL N/A RECOMMENDATION NOT PREFERRE VIABLE D There are a number of issues that require further clarification/negotiation by Croydon CCG and CSU before SLAs are signed in October 2012: Level of prescribing non-pay Finalisation of accommodation costs and arrangements Clarity on Primary Care IT funding stream Refine performance management / escalation process Clarity on depreciation on IT Clarity on treatment of non-recurring change management costs under the running cost definition ( 200k/ 0.55 risk on project resources and costs of Better Services Better Value) 36

37 Appendix 6: Memorandum of Understanding and Framework for a Service Level Agreement Memorandum of Understanding And Framework for a Service Level Agreement To describe the relationship between South London Commissioning Support Unit and Croydon Clinical Commissioning Group 37

38 Contents Page Section 1 Introduction 2 Section 2 Outline of Terms and Conditions agreed 4 Section 3 Services to be provided 6 Section 4 Operating Model 7 Section 5 Pricing 8 Section 6 Performance management 8 Section 7 Governance 10 Section 8 Signatures 13 Schedules Schedule 1 Vision, values and commissioning intentions of Croydon CCG (not included here) Schedule 2 Service descriptions, including key performance indicators Schedule 3 Pricing Schedule 4 South London CCG and South London Commissioning Support Unit Organisational Development narrative to support authorisation V3.1 (21/8/12) 38

39 Memorandum of Understanding 1 Introduction 1.1 Context The South London Commissioning Support Service (CSU) and the emerging Croydon Clinical Commissioning Group (CCG) have been working together to develop arrangements for commissioning support during 2012/2013, and post authorisation, whilst recognising that during 2012/13 NHS Croydon Primary Care Trust remains the accountable body. In order to support CCGs as they prepare for authorisation, and to support the development of the CSU in such a way as to meet its own authorisation requirements, it is expected that this Memorandum of Understanding (MoU) describes in sufficient detail the proposed offer of the CSU to meet both organisations needs at this stage. It also recognises a shared commitment to co-develop the detail required to conclude a robust Service Level Agreement (SLA) by October This MoU and subsequent SLA will govern the relationship between the two organisations, as they work in shadow form until March 2013, and from April 2013 onwards It is important to recognise that this is new territory for both the CCG and the CSU. This MoU describes the intended principles and content expected to be reflected in the SLA. Both parties will be as specific as they can be during the development of the SLA. In order for the CCG and the CSU to demonstrate that sustainable plans for commissioning support are in place to support authorisation, the parties agree to a four year partnership (transition year plus three years, with the possibility of further extension) that will be further described and developed during 2012/13 and reassessed on an annual basis, subject to the termination arrangements described in this document. 1.2 Mutual intentions underlying this Agreement The CSU recognises and appreciates the importance of having the CCG as one of its key customers, who are seen as critical to the future success of the CSU. In the same way, the CCG recognises the importance to it of the successful development of the CSU. The CSU and the CCG view this relationship as a collaboration that will help build two successful new organisations. The support provided through the services listed in this Agreement is seen as an important part of the authorisation process for the CCG. 39

40 The CSU commits to supporting the CCG throughout this authorisation process. To enable the CSU to deliver services effectively the CCG commits to engaging constructively with the CSU to help improve services as both organisations develop. 1.3 Objectives of development of the relationship of between the CSU and the CCG The shared objective of both parties is to secure high quality commissioning support services, supporting the CCG in commissioning the best possible health care services for the residents of Croydon within the available budget. The cooperation defined in this MoU will help achieve this objective, by allowing the CCG to get best value for its commissioning budget through economies of scale the CSU can offer, and by helping the CCG access additional expertise, technical skills and infrastructure. This will allow the CCG to focus on core strategic commissioning decisions and exercising clinical leadership. The CSU regards the CCG as one of the foundation customers for its business. The benefits and implications of this are outlined in Schedule 4 South London CCG and South London Commissioning Support Unit Organisational Development narrative to support authorisation V3.1 (21/8/12) The CSU commits to working with the CCG to ensure a long-term financially sustainable offer. The CSU will be transparent about what it costs to provide services to the CCGs, but must retain a margin on top of costs so as to invest in improving services and developing new products. 1.4 Learning process as part of initial cooperation Both parties recognise that 2012/13 will be a period of learning for both the CCG and the CSU. They agree to work closely together to ensure the learning process will be as constructive as possible. The CSU commits to collaborating with the CCG to refine commissioning support services year on year to meet the CCG s commissioning support needs, as both organisations and the environment in which they operate evolve. 1.5 Process going forward Both parties recognise that during 2012/13 the new commissioning system is developing. Both parties therefore agree to cooperate closely and agree to be guided by the principles and spirit of this MoU. 40

41 During 2012/13, the CSU will support the CCG in their commissioning and their related processes to achieve authorisation. The parties will meet regularly to evaluate progress during this time of development. The CSU and CCG will work together between April 2012 and October 2012 to refine and detail specific elements to be included in the SLA, including defining Key Performance Indicators and any additional services to be incorporated. The CSU and CCG will meet formally in or before October 2012 to conclude the Service Level Agreement, including: KPIs Delivery model for the services Performance management arrangements Any additional services to be included in the offer and the charge for these It is anticipated that by October 2012, the key leadership team and other staff in the CSU will be in post and the delivery of services to CCGs will have started. However, whilst every effort will be made to ensure the new CSU organisation is operational by October 2012, it is unlikely that all staff and infrastructure will be in place until subsequent months. Similarly it is unlikely that all CCG staff will be in post. The period to March 2013 will be one of intense development. During this period, both parties will aim to operate as far as possible to the standard set in the SLA, although the formal SLA will not be effective until April 2013 The next formal review point (after October 2012) will be in February / March 2013, in which both parties will finalise the thresholds to be set on the KPIs and the handling of performance issues. After this, the SLA will be reviewed on an annual basis. The timescales outlined in this MoU are based on the current understanding of future developments within the national system. Both parties recognise that any changes to this may impact the time lines and therefore require an update to this MoU It is possible that the NHS Commissioning Board will define mandatory national services in specific areas, which may require reassessment of specific CSU services. This agreement, and the subsequent SLA, may be superseded in the future by a national model contract but it is anticipated that the core content will remain the same. 2 Outline of Terms and Conditions agreed 2.1 Introduction The CSU is the commissioning support function created through a partnership of the clusters of South East London and South West London, set up to support clinical commissioning groups (and other customers). 41

42 The CSU will work closely with the CCG in the transition period until April This collaboration will be underpinned by this MoU and subsequent SLA that makes explicit what the relationship and deliverables will be in practice. This MoU outlines key relationships and contacts the services to be provided, set out in section 3 the operating model, set out in section 4 the agreed pricing, set out in section 5 the performance management approach, set out in section 6 and the overall governance approach, set out in section 7, including escalation procedures if either party is not happy with the execution of the MoU. The operating model and the performance management sections of this MoU may be revised as needed in October 2012 as part of the SLA. 2.2 Duration This agreement shall be valid until it is superseded by a formal SLA. It is anticipated that the SLA will be effective from April 2013 and valid until March It will be reviewed regularly and formally on an annual basis. 2.3 Variations Additional areas of commissioning support can be added over the period of this MoU and the subsequent SLA. These will be mutually agreed and will be formally appended to any agreement as a variation. CCGs will be able to give notice on areas of commissioning support in accordance with the terms of the notice of the SLA. 2.4 Terms and termination This agreement and the subsequent SLA will remain valid unless superseded by a revised agreement mutually endorsed by both parties. The MoU and subsequent SLA will outline the parameters of all services covered as they are mutually understood by both parties as set out in section 3 and Schedule 2. The CCG and the CSU recognise the importance to both of the stability and sustainability of commissioning support services. The CCG needs to balance this with retaining appropriate flexibility. The CSU and the CCG have therefore agreed that this MoU, and the subsequent SLA, may be terminated in whole or in part by either of the parties prior to the formal expiry date, subject to giving notice in writing, as follows: 42

43 a) for the core services and for ICT for Primary Care services twelve months notice b) for enhanced services six months notice. In addition, a process for partial or complete termination as a consequence of performance issues is outlined separately in section 5, performance management. The SLA will be automatically renewed on an annual basis after the initial contract period of three years, unless either party requests a contract renegotiation at least 12 months prior to the contract expiry date. 2.5 Lead Contacts in relation to the MoU The key contacts in relation to this MoU are: For the CSU: Nick Relph, Interim Managing Director For the CCG: 2.6 Previous agreement This MoU supersedes the Memorandum of Understanding between the parties dated 29 th March Services to be provided 3.1 Commissioning priorities for Croydon CCG The CSU will support the CCG in delivering its commissioning plans and priorities, through the delivery of the services outlined in this section. The CCGs vision, values and commissioning intentions are included in Schedule Provision of Core Services This paragraph lists the portfolio of services the CSU will provide to the CCG as part of the Core Service offering (the Core Services ). More detailed service descriptions are set out in Schedule 2. Acute contract management (including quality) Individual Funding Requests (IFR) management Provider Performance Management Advice & Support on Clinical Procurement Performance and activity reporting and analysis Financial Governance & Control, Counter Fraud Financial Management and Planning 43

44 Estates and health and safety Human Resources and organisational development Purchasing (non-clinical) ICT Support Communications and Engagement 3.3 Customised agreement The parties recognise that some customisation of these services may be required to meet the specific needs of the CCG and that further work may be required to define this. 3.4 Enhanced Services In addition to the Core Services, the CSU will offer the CCG additional services (the Enhanced Services ). The CSU and CCG are still in the process of developing the detail for these additional services and expect to reach firm agreement by October Operating model 4.1 A mixed delivery model This section describes the planned operating model for the delivery of CSU services. Whilst this represents the current position, the parties acknowledge that this may vary from time to time to ensure that services are delivered effectively and efficiently. The CSU will deliver its services to the CCG through a mix of local dedicated staff, multi-disciplinary teams working across a number of CCGs, based locally, and some centralised resources. This allows for the service provision both to reflect local needs and to benefit from the economies of scale and skill that the CSU is set up to deliver. 4.2 Dedicated local staff Details of staff dedicated to the CCG and their physical location will be identified as part of the October 2012 SLA. 4.3 Staff teams working across a number of CCGs Some CSU staff will be based in multi-disciplinary teams supporting a group of CCGs. The multi-disciplinary team is likely to consist of staff working on: Acute contract Management (including quality) 44

45 Individual Funding Requests Provider Performance Management Performance and activity reporting and analysis Financial management, in relation to the above 4.4 Central support There are some functions which are best delivered centrally, once only to deliver maximum effectiveness and Value for Money. These are likely to include: IT infrastructure HR services Invoicing and payroll Procurement Accounting and financial management 4.5 Roles of Account Directors and Account Managers Each CCG will have: One named Board Level Director of SL CSU to be the accountable person for delivery of the totality of their commissioning support offer, known as the Account Director A relationship managers who will be based locally to ensure for accessibility, known as the Account Manager Named contacts for each service who will respond to day to day issues Nominated Account Directors and Account Managers will attend CCG meetings to oversee the delivery and performance of the SLCSU services. The CCG will identify a named officer (the Nominated Officer ) to lead on matters relating to the contract with the CSU, including monthly performance meetings. 5 Pricing 5.1 Total price for the core offer Subject to agreement of the SLA, the CSU will provide the CCG with the Core Services and the Enhanced Services described in Section 3 for the price set out in Schedule 3. At this stage, this is an indicative sum, at 45

46 2012/13 prices, and may be subject to change as service development and SLA negotiations proceed. This pricing will be revised on an annual basis, based on inflation, mutually agreed changes to the service delivery, changes to national policies and regulations and other factors influencing the costs to the CSU. Payment will be monthly in advance, subject to any NHS CBA guidance on the financial regime for commissioning support units. 6 Performance management 6.1 Introduction Performance management by the CCGs of the CSU will comprise a range of measures, which are outlined below and which will be detailed in the October 2012 SLA. 6.2 CSU performance assessment survey As an overarching method of collecting qualitative feedback, the CSU will send out a regular performance assessment survey to the CCG, to be filled out by key people in the CCG, including the Chair and Accountable Officer. It will be co-designed to ensure it is effective, but does not become an unhelpful burden on CCG time. This survey will be a key input to quarterly performance reviews. This survey will be used to evaluate the qualitative aspects of the CSU services rather than quantitative benchmarks. The CSU will consolidate the responses, and communicate them back to the CCG as an integral component of the performance report. Any areas that are red or amber will be addressed in the quarterly performance review. The survey will be co-developed with CCGs and used to inform the priority areas for improvement. 6.3 Key performance indicators by service line In addition to the CSU performance assessment survey, the CSU will measure its performance on a set of key performance indicators by service line and communicate this back to the CCG on a regular basis. These will be introduced on a trial basis in the period from October 2012 to March The draft KPIs are set out in Schedule 2. 46

47 By April 2013, the CCG and CSU will agree on the target performance levels for these KPIs and the consequences of meeting, exceeding or not meeting these levels. 6.4 Monitoring & review process The monitoring process for this MoU and subsequent SLA is as follows: Monthly (or at different frequency as mutually agreed) The CCG Nominated Officer and the Account Manager will meet to discuss the overall development of support from the CSU. They will specifically address any performance issues raised with the Account Manager and any the KPIs that are below the agreed threshold. The CCG and the CSU will agree on an approach to address any performance issues. Quarterly The CCG Nominated Officer, the CCG Accountable Officer (if different), the Account Manager and the Account Director will meet to discuss the overall performance and development of support from the CSU, discuss the results of the performance assessment survey and to address any performance issues previously raised in the monthly reviews. Annually - The CCG Nominated Officer, the CCG Accountable Officer (if different), the Account Manager and the Account Director will meet to discuss the following topics: Evaluation of last year s cooperation and key areas for attention next year. Any adjustments to the details in the SLA for next year, in terms of services included in the SLA, pricing, the operating model and/or adjustments to the performance management system. 6.5 Management, escalation & remediation process There is a responsibility on both parties to support delivery in line with the specification. If this is not the case, this should be raised with the relevant service delivery lead. All reasonable endeavours at a local level will be completed before escalation to the next stage. The proposed escalation procedure for matters not dealt with in this way, or resolved as part of the monitoring process described in paragraph 6.4, is as outlined below: 47

48 Stage 1 escalation to Account Manager: An issue of material concern should be stated clearly, confirmed by or letter, to the CCG s Account Manager. The Account Manager will convene a resolution meeting if needed, investigate the concern and formally respond to the CCG within [3] working days. Stage 2 escalation to CSU Account Director: If the matter has not been satisfactorily resolved, or is not being satisfactorily addressed, the Account Manager and CCG will jointly agree that it should be escalated to the Account Director of the CSU for resolution, who will review the concern from the CCG, the investigation and attempts at resolution to date, meet with the CCG if necessary and formally respond to the CCG within a further [5] working days. Stage 3 agreement of an improvement plan for performance issues: If performance issues cannot be resolved there will be an agreement of a specific and agreed improvement plan and joint monitoring that will be in place until the performance has improved. Stage 4 dedicated delivery improvement team: Where the performance has failed to improve following the improvement plan and joint monitoring a commitment of a dedicated delivery improvement team funded by the CSU may be put in place to resolve the issue. Stage 5 market test The CCG may ultimately decide to tender either the specific service or the full service offering, in line with national policy if a resolution cannot be reached. 7 Governance 7.1 Overall communication between both parties The named Account Manager for the CCG will be single point of contact for the integral portfolio of services, and will work with the CCG to ensure the CSU support meets the CCG s needs. For daily operations, the CCG will communicate directly with the CSU service leads responsible for delivery of the service. These service leads will be identified as the CSU appoints staff to key posts during the period to October. The CCG will identify named leads to work with the CSU on a transactional basis, for example, around troubleshooting operational IT issues. 48

49 In case of any issues that cannot be resolved as part of daily operations, the escalation process outlined in section 6.5 will apply. 7.2 CSU business strategy and development The CSU and the South London CCGs will establish a Strategic Advisory Group to advise the CSU management team on strategic direction and on priorities for investment, innovation and service development, as set out in the recommendations of the July/August 2012 working group (Schedule 4). 7.3 Roles and Responsibilities In addition to the specific responsibilities for the individual services as defined in Section 3 and Schedule 2, the CSU and CCG commit to meeting their responsibilities as part of this partnership, as set out below: Commissioning Support Service The CSU commits to working with the CCG in a way that is appropriate to the CCG and meets its needs. The specific responsibilities of the CSU in the delivery of services have been outlined by service in Schedule 2. In addition to these responsibilities with respect to the service delivery, the CSU sees the following as its overarching responsibilities: Support delivery of CCG priorities, Commissioning Plan and financial management. Work with the CCG to ensure the support agreed as part of this MoU is part of an overall delivery model that will enable the CCG to achieve its objectives. Work closely with CCG leads in the delivery of all CSU services, and in particular those related to contract negotiation and provider performance management, so that the CCG maintains the provider relationship and clinical leadership. Engage with the CCG on an ongoing basis on any issues or concerns that may arise as we support the CCG, and agree how these will be addressed. Look beyond the CSU direct responsibilities defined in this MoU and subsequent SLA and be a strategic partner to the CCG, using the CSU understanding of the overall health system to provide the CCG with advice when asked to, and proactively raise matters for attention. Provide the CCG with advice and support where possible in the CCG s interactions with other stakeholders in the national health system, such as the National Commissioning Board and local 49

50 authorities the CSU sees supporting the CCG in the process to authorisation as a crucial first step in this. Work to agreed deadlines, and ensure we agree on clear deadlines where these are not already in place as part of standard service delivery. Incorporate feedback received from the CCGs in the regular performance reviews, and address performance issues as a key CSU priority. The Clinical Commissioning Group For the Commissioning Support Service to be able to deliver the services covered within the MoU effectively, both parties will have to work closely together. The specific responsibilities the CCG has in the delivery of the specific services are outlined in Schedule 1. In addition to that, the CCG agrees it has the following overarching responsibilities to support effective co-operation with the CSU: Provide the CSU with clarity on its priorities on an annual basis, and as they change throughout the year, so finite resources can be allocated optimally. Provide the CSU with access to all data sources relevant (subject to Information Governance protocols) for the support functions they are providing through data sharing agreements. Provide the CSU with sufficient access to lead contacts who will work with the CSU on effective service delivery. Engage the CSU as early as possible in any relevant stakeholder engagements that will require some form of CSU support (such as financial reports). Coordinate with the CSU on communication towards the providers and other relevant stakeholders, to appear as one united team. Directly inform the CSU of any matters that may impact the services provided by the CSU, for instances incidents that will translate into high media attention Provide the CSU with regular and constructive feedback on the service delivery as agreed in the performance management section, and in case of performance issues, work with the CSU on resolving this issue as part of a trust based partnership. 50

51 8 Signatures Signed on behalf of South London Commissioning Support Services Name: Nick Relph Role: Managing Director Signature: Date: Signed on behalf of Croydon Clinical Commissioning Group Name: Role: Signature: Date: 51

52 Appendix 7: Integrated Commissioning Unit with the Local Authority A Memorandum of Understanding is currently in development with the Local Authority. This appendix sets out the rationale for the integrated commission unit and the expected benefits. 1. Introduction 1.1 The Health and Social Care Act 2012 brings into being major changes to local health and social care systems. These include: Changes to the commissioning of NHS services Changes to who is responsible for local public health A far greater focus on integrated planning, commissioning and provision of services A focus on improving health outcomes and reducing health inequalities. 1.2 Primary care trusts (PCTs) are to be abolished and, from April 2013, responsibility for commissioning health services will be transferred to clinical commissioning groups (CCGs) and the NHS Commissioning Board. Local authorities retain responsibility for the wide range of services delivering social care, and adding to general wellbeing, but responsibility for public health improvement is now added. 1.3 CCGs, made up of GPs working closely with professional and clinical colleagues and patients, will commission a range of clinical services including most hospital and mental health services. Primary care and regional specialist services will be the responsibility of the NHS Commissioning Board. Every GP practice must be a member of a CCG, and every CCG must be represented on a Health and Wellbeing Board. 1.4 Shifting primary responsibility for commissioning NHS services from PCTs to CCGs is a significant organisational change for the NHS. The roles and responsibilities of GPs, especially those on the CCG board, will change from assessing the health needs of their patients at a practice level to planning for the health needs of the whole local population, including people who are not registered with GPs and who often have the most severe health needs. Commissioning local health services will also bring with it a significant change in budgetary responsibility. 1.5 Beyond some minimum requirements, evidenced through the current process known as authorisation, CCGs will be able to decide their own organisational form, governance arrangements and priorities, and will be able to contract out commissioning services both support and direct commissioning to councils, the private sector, not for profit organisations and NHS commissioning support services. In order to fulfil commissioning obligations CCGs will receive a per capita level of funding (capped at 25 per registered population scaled to ONS population projections) from the NHS Commissioning Board, to which they are accountable. Other accountabilities are through Health and Wellbeing Boards. 52

53 1.6 In the run up to implementation all Primary Care Trusts and CCGs have entered into meaningful dialogue with local authority partners, utilising Health and Wellbeing Boards and other local arrangements to discuss options for appropriate new models for both commissioning and delivery. 1.7 Discussions began in Croydon in mid 2011 to strengthen and extend a set of existing formal arrangements that had begun a number of years previously as joint commissioning around the needs of certain groups of social care serviceusers. The intention to move towards a more mature, integrated commissioning model gained pace and, following consultations across the organisations concerned, a process formally commenced in January 2012 to gather ideas and options for future models. 1.8 Commissioning is the process for deciding how to use the total resources available in order to improve outcomes in the most efficient, effective, equitable and sustainable way. The drivers for integrating commissioning include not only a recognition of a new architecture for the NHS, as described above, but also the major challenges of using resources more efficiently and of meeting the needs of an ageing population in which chronic medical conditions (such as diabetes, Chronic Obstructive Pulmonary disease and various dementias) are increasingly prevalent. A joint approach between the NHS and local government will focus much more on preventing ill health, supporting self-care including through personalisation, enhancing primary care, providing care in people s homes and the community where this can be done more appropriately than in hospital settings, and increasing co-ordination between primary care teams and specialists, and between health and social care. 1.9 Both the NHS and local government in Croydon acknowledge the growing place for expert commissioning in the delivery of both efficiency and effectiveness. Both also recognise the risks inherent in any dilution of the strength offered by our local health and social care economy. Nevertheless, the benefits of integrating commissioning have to be explicit, including financial benefits. 2. Benefits 2.1 This paper and the proposal it sets out provides a broad framework for local health and social care leaders consideration, and is not a fixed model. The paper concentrates on integrated commissioning in Croydon and the window of opportunity presently available. 2.2 Integrated commissioning means consolidating and developing our current joint commissioning arrangements across the Council and CCG - extending and strengthening them in the areas of social care and health for adults and children, individuals who need support, their family and carers. 2.3 In terms of commissioning for children and families it has been recognised that there has been significant commissioning under-capacity across both Health and the Council to achieve success in this area which both agencies agree is a core 53

54 priority. There is now a positive opportunity to move forward together to support models of commissioning and build the right levels of support 2.4 There may be differences in terms of commissioning cultures and procurement guidelines between the NHS and local authorities but the Council s Commissioning Strategy ( ) and the NHS Procurement Guide for Commissioners of NHSfunded services describe similar processes for commissioning involving: - information analysis and population needs assessments; - market analysis; - service specification; - provider engagement; - evaluation of procurement options; - tendering / a process of selection of suitable providers; - development and mobilisation of contracts; - monitoring of service quality and efficacy; - management and control of budgets and evaluation. 2.5 The current arrangements do not optimise the capacity we have across the whole system. Any solution responding to new demands has to embrace the need to move away from duplicating resource across the system. 2.6 Overall goals for Croydon s Integrated Commissioning Unit (ICU) include: Supporting the delivery of QIPP Enhancement of preventative services and early intervention Maximising community-based delivery through integrated commissioning Reducing the use of unplanned acute or urgent care wherever possible Supporting integrated delivery of care & support Drawing on the grass-roots experience and distinct role of the third sector Acting on the genuine experience of patients and Croydon residents Personalised care, closer to home Continuity, by anchoring existing joint commissioning at the Croydon level, mitigating the risk of organisational memory loss or management control, which could occur with further migration of NHS functions and staff Strong co-ordinated interface management with other local CCGs and joint management of the market of providers; and not least A guarantee that all commissioned services provide demonstrable value for money and are sustainable. 3. Principles 3.1 The proposal being made is that a set of separate commissioning functions with some integration at commissioning management levels, which we currently describe as joint commissioning, will be brought together into a co-located and integrated commissioning unit (ICU). Some of the staff involved in the unit will be employed in the NHS and the remainder will be Council employees. This model is predicated on being co-located in Bernard Weatherill House. 54

55 3.2 It is important that in terms of governance and points of accountability there continues to be a recognition that staff from those respective groups retain responsibilities and accountability within their own organisations. At the same time there will be an acknowledgement of the shared responsibilities the Unit (ICU) will take on as the commissioning function acting on behalf of the CCG. 3.3 A set of terms of reference has been set up for an Integrated Commissioning Board, overseeing the development of the ICU, which has representation including Directors of CFL and DASHH for the Council, and Chief Operating Officer and Directors of Commissioning and Governance and Quality for the CCG. The Board also has representation from the Director of Public Health, whose functions are due to transfer to the Council from the NHS in April Four work streams have been established: organisational development (taking in human resources and facilities management); outcomes and performance; relationships and governance and transformation and redesign (capturing the efficiencies gained through a single approach to commissioning). 3.5 The ICU terms of reference establish a commitment to: Respond to health and wellbeing analysis in Croydon and act to deliver outcomes-based commissioning based on joint decision-making and efficient and effective resource deployment. This will involve: pooling information across the health and wellbeing system; agreeing shared priorities and desired outcomes; pooling and developing commissioning expertise; agreeing how to use collective financial and other resources more effectively Oversee and provide governance for the setting up of an integrated commissioning function (within 18 months) for health and wellbeing that will undertake local commissioning functions on behalf of CCG and Social Care and Public Health functions of the Council. This will involve: planning the transition to integrated commissioning; overseeing the practical process of organisational development for an integrated commissioning function; building sustainable governance arrangements and accountability within a new health and social care landscape; building and maintaining effective, business-like relationships with key stakeholders Ensuring a comprehensive and effective commissioning framework that represents best practice, and the required skills, capacity and access to enabling support. This will involve: supporting a model that includes needs assessment, market shaping and management, spend and income analysis, business 55

56 case development, specification of requirements, tendering and contract management and evaluation; ensuring personalised outcomes for individual service users and patients Ensuring a comprehensive and effective programme and project management framework for the organisation, as it develops: developing clear procedures, practices and skills development. This will be achieved through: the programme of workstreams identified Ensuring an effective risk management system is in place Supporting the CCG in the process towards authorisation as a competent commissioning organisation. This will be achieved through: planning a range of complementary activity within the given timescales that will provide the necessary assurances to the NHS National Commissioning Board 3.6 The scope of the ICU will include: Children s Commissioning People with Long-term chronic conditions, including Older People Physical disabilities and sensory impairment End of life care People experiencing Mental ill-health Mental Health of Older people, including people with dementia Planned care Urgent care Drug and alcohol misuse Supported housing and other support to vulnerable adults Learning disability Support to family carers Aspects of sexual health 3.7 This proposal allows for a hybrid model of commissioning enabling support. It recognises that a number of specific functions such as Business Intelligence, major clinical procurement and other commissioning support functions could be supplied to the CCG by any appropriate provider. These include the Commissioning Support Service at sub-regional level (South London CSS) as well as the operating model within the Council that locates its commissioning and procurement, strategic intelligence, programme management office and risk management functions within SCPP (Strategy, Commissioning, Procurement & Performance). These functions will be called on according to criteria such as scale. 3.8 As we move into implementation of the ICU we will be targeting efficiency savings mainly derived from realising benefits through the services we commission and the 56

57 outcomes we expect from them. There will also be some benefits to be derived through productivity gains, and potential savings to be achieved by the elimination of overlaps in the responsibilities of posts as we move from a lifted and dropped (joint) service to a fully integrated service over time. 3.9 The transfer of many public health functions and staff to the Council and their colocation with health and social care commissioners will also give important support and synergies to integrated commissioning. This will be additional to the role public health skills will play in enabling the CCG in their decision-making capacity. It is also anticipated that the Council will itself benefit from expertise and skills brought by NHS commissioning staff, along with longer-term prospective savings that could flow from truly aligning our commissioning together in partnership in an era of on-going budget reductions and economic stasis The ICS does not need to move to pooled budget arrangements to be effective. As with much of our current commissioning, good results can flow from jointly aligning our planning, procurement and re-design of services and systems, albeit it has long been recognised that transactional activities (billing, invoicing) from Health to Council and vice-versa generate considerable cost. However, should the CCG and Council wish to explore pooled budgets in the future for local Borough based services, including integrated delivery, then the foundations will be soundly in place with good local intelligence on cost and quality from both a health and social care perspective along with a clear governance framework for the ICS supported by a formal partnership agreement The core purpose of the ICS would be to support the decision-makers to carry out their statutory functions by planning the most effective use of resources and implementing their decisions with regard to the services to be commissioned - a broad range involving children, adults, older people and the majority of non-acute provision. The ICS will sustain and strengthen our current joint and aligned commissioning arrangements by optimising organisational, process and systems efficiencies and by spreading overhead costs amongst partners There may be circumstances when there will be differences in priority-setting and the consequent commissioning decisions that could be made by the Council or CCG. To an extent these differences already occur under the current organisational arrangements. Critically, in the future, the role of the Health & Wellbeing Board in identifying mutual commissioning priorities through the local Health & Wellbeing strategy should provide evidence-based support to both the CCG and the Council in their decision-making capacities. As now, in the areas where joint commissioning has long been established, there would be clear expectations across both the CCG and the Council that, if and when such differences arise, the ICS will have the leadership capacity and systems to manage these effectively The development of governance arrangements for the ICS are the responsibility of a Joint Management Board comprising CCG and Council senior personnel, supported by a formal (currently draft) Memorandum of Understanding. Staff currently employed through the PCT will retain their status as NHS employees by 57

58 virtue of the CSS having acquired responsibility as the employing organisation on the understanding that this is for an initial period of 18 months and that the CCG has taken on the ongoing risk associated with those staff. Over time there will be the opportunity to reflect both nationally and locally on possible future contractual arrangements for health staff working in integrated commissioning units based within local authorities. 4. Summary of Principal Benefits and Next Steps 4.1 This paper has attempted to make the case for harnessing the benefits of greater integration between the commissioning arms of the two organisations in the Borough charged with commissioning services to meet social care and health need. 4.2 The ICU proposal is a practical solution to support the CCG in gaining traction as a new commissioning organisation as well as sustaining the focus and capacity in Croydon on Croydon people and Borough needs. 4.3 The proposal to establish an ICS is based on a wish to mitigate the risk of our current strong joint commissioning arrangements becoming fragmented, and the strong belief that we can drive out significantly greater opportunities for quality, innovation, productivity and prevention (QIPP) through commissioning, thereby improving services for local people by achieving optimum value in challenging financial times. 4.4 The proposal involves minimal structural disruption with ability to sustain expertise & knowledge and sensitivity to local needs. We need to move to a new model to: - avoid duplication and maximise efficiencies - improve capacity for children s commissioning for both the CCG and council - re-design pathways and implement commissioning changes from secondary to primary, with a focus on community-based support This proposal outlines a thoughtful, measured process for doing so. 58

59 Appendix 8: DRAFT Memorandum of Understanding with Public Health MEMORANDUM OF UNDERSTANDING between Croydon Council and CROYDON CLINICAL COMMISSIONING GROUP for the provision of Public Health Commissioning Support Version Control Version Author Date Comments v1.0 Kate Woollcombe First Draft circulated for comment to: Tony Brzezicki, Agnelo Fernandes, Paula Swann, Jon Rouse, Hannah Miller, Fouzia Harrington, Steve Morton, Jenny Phaure, Mike Robinson v2.0 Kate Woollcombe Reflects comments received to date v3.0 Kate Woollcombe Reflects further discussion at CCG Management Team 23 October

60 Purpose of the Document This document sets out a framework describing the nature and extent of the developing relationship between the Croydon Clinical Commissioning Group ( the CCG ) and the Public Health ( PH ) team currently based within the NHS, and due to transfer to Croydon Council on 1 April Context Under the Health and Social Care Act 2012, much of the public health function currently delivered within the NHS becomes the responsibility of local government. This means that councils will be taking on responsibilities across the three domains of public health: health improvement, achieved through coherent inter-agency action tackling lifestyle and other factors ( the wider determinants of health ) that influence health and wellbeing health protection, eg by preventing the spread of communicable disease, managing the public health response to major incidents, and monitoring the delivery and effectiveness of local screening and immunisation programmes as commissioned by the NHS Commissioning Board healthcare public health, providing specialist advice to support and inform the commissioning of effective and safe healthcare services to meet population need Local government has been mandated to ensure that Clinical Commissioning Groups are provided with the necessary public health advice and input to support effective delivery of their statutory responsibilities. Aims and Objectives The CCG s vision is to achieve Longer, healthier lives for all the people in Croydon. To that end, the partnership between the CCG and the PH team will have the following objectives: to develop a shared understanding of the nature and extent of the issues affecting the health of Croydon residents to develop effective strategies and interventions that will o secure health improvement and reduce inequalities in the population o have a positive impact on quality of life and healthy life expectancy Working Arrangements 1. The PH team will expect to develop close working relationships with the Joint Commissioning Unit and the Commissioning Support Service for South London, in order to be able to effectively advise and support the CCG in its commissioning decisions. 2. The CCG and PH team will formally agree an annual work programme that is informed by, and consistent with: local goals and priorities as set out in the Health and Wellbeing Strategy (HWS) and the CCG s Integrated Strategic Operating Plan (ISOP) national requirements and expectations, established and emerging the resources available The work programme will include core work, such as the JSNA, Annual Public Health Report, Health and Wellbeing Strategy, and task and finish projects in line with agreed priorities. An early draft is provided at Appendix 2. 60

61 3. The PH team will be active and consistent members of a range of groups in which the CCG has an interest, to be agreed as part of the annual work programme. 4. The PH team will support all member practices in delivering health improvement by assigning a named consultant lead to each GP network. 5. It is expected that there will be some areas of work which are best tackled across a number of CCGs, and that in such cases PH support to commissioning will need to be provided at scale. This means that some Croydon PH staff will have SW London-wide responsibilities, and in return that Croydon CCG will receive PH support from other borough teams. 6. As a statutory partner in the production of the local JSNA, the CCG will ensure active representation from the Governing Body and/or Clinical Leadership group, actively participating in the prioritisation and action-planning processes. 7. The CCG will actively contribute to the development of the Health and Wellbeing Strategy. Domain Specific Activities Health Improvement 8. In line with priorities agreed by the Health and Wellbeing Board, the PH team will advise on and support the development of action plans to improve health and reduce health inequalities the design and delivery of local public health campaigns and related health improvement activities 9. The CCG will contribute to the development and implementation of strategies and action plans to improve health and reduce health inequalities, eg through all member practices addressing smoking, alcohol misuse, and obesity in their patients by actively supporting local PH campaigns and other preventative activities, including opportunistic health promotion with individual patients by ensuring that prevention and the principle of proportionate universalism (ie, actions must be proportionate to the degree of disadvantage, hence applied in some measure to all people rather than only the most disadvantaged) underpins their commissioning decisions 10. The CCG Governing Body and Clinical Leadership Group (CLG) will ensure that their member practices play their full part in achieving key public health targets (eg immunisations, screening, smoking, health checks) Health Protection 11. The PH team will ensure that local strategic plans are in place for responding to a range of emergencies, including pandemic flu, major incidents, and adverse/extreme weather conditions capacity and skills are in place to co-ordinate an emergency response (this may be managed on a SW London-wide basis) specialist health protection advice, including but not limited to advice on screening and immunisations, is available to primary care clinicians; this may be provided from local, sector, or London-wide resources 61

62 12. The CCG will ensure that they have the necessary policies and procedures in place to deliver their role as a Category 2 responder under the Civil Contingencies Act, and participate in major incident exercises where relevant. 13. As commissioners, the CCG will ensure that all providers of their commissioned services have major incident and business continuity arrangements in place, appropriate to the nature and extent of the service provided. 14. The CCG will ensure that all member practices have tested business continuity plans in place, and that resources can be made available in the event of a major incident to assist with the response, including participation in local command and control arrangements. Healthcare Public Health 15. The public health team will lead the annual joint strategic needs assessment (JSNA) process, with particular emphasis on identifying the nature and extent of health inequalities in the borough undertake ad hoc needs assessments/service reviews/service evaluations in line with the agreed priorities for the year advise on and support the design and delivery of evidence-based care pathways advise on and support the delivery of evidence-based commissioning and procurement decisions advise on and support the design and delivery of strategies to reduce health inequalities and unwarranted variation in health outcomes assist the CCG with determining priorities and identifying areas for investment/disinvestment using appropriate methodologies support the CCG in ensuring the clinical effectiveness and quality of commissioned services through participation in governance and clinical quality review groups contribute to the development and revision of evidence-based criteria for the commissioning of services, including referral and demand management criteria provide specialist public health input to the Individual Funding Request process lead the development and publication of the Pharmaceutical Needs Assessment 16. The CCG and (where appropriate) member practices will: support the development and publication of the Pharmaceutical Needs Assessment by ensuring that the PH team has access to appropriate levels of specialist advice to enable delivery of this statutory responsibility engage with and support the implementation of NICE and other best practice guidance relevant to Croydon work together with PH to implement agreed commissioning priorities and programmes, and demand management strategies Resources The PH team in Croydon comprises the Joint Director of Public Health (DPH), supported by 5.00 wte consultants (one of whom is the designated Deputy Director of Public Health (DDPH), one assistant director, and their teams. From time to time, specialist trainees are placed with the PH team. The total PH team establishment and skill mix as at 31 March 2013 is shown at Appendix 1. 62

63 The pay budget and associated non-pay costs for the PH team will be fully covered by the allocation received by Croydon Council. If not co-located, hot desk facilities for visiting members of the PH team will be required. Access to Data To enable the PH team to discharge its responsibilities, appropriate individuals will require continued and free access to raw and aggregated NHS data through the Data Management Information Centre. The CCG will be responsible for ensuring that this access is maintained, where the data are held by their commissioning support organisation/s. Appendix 3 contains a schedule of the data required by the PH team. requirements may change over time. These Governance The DPH will ensure that the work programme is delivered by staff with appropriate levels of knowledge, skills, and experience for the task in hand. Systems will be in place to ensure that staff have current registration, where this is a pre-requisite for appointment to, and continuing in, their role. All staff will be expected to participate in ongoing professional development, and to comply with the CPD requirements of their professional bodies as applicable. The DPH will ensure that the department meets the required criteria for accreditation as an approved training location for specialist public health trainees. Appointments to consultant posts within the PH team will be subject to the prevailing Faculty of Public Health guidance and procedures, including the establishment of an Appointments Advisory Committee whose membership includes Faculty representatives. The DPH will meet regularly with the CCG Chair and Accountable Officer to review progress with delivery of the agreed work programme, amend/update it as necessary in the light of developing or changing priorities, and to agree any remedial action that may be necessary. Date of Review April 2013 Appendices 1. Croydon Council PH Team: funded establishment and skill mix 2. Specimen Work Programme 3. Data Requirements 63

64 Appendix 1: Public Health Department: Funded Establishment as at 31 March 2013 [to be added] Appendix 2 Draft Work Programme Core Work Annual Public Health Report JSNA Overview Chapter JSNA Deep Dives as agreed by the Health and Wellbeing Board Public Health contribution to the Integrated Strategic Operating Plan GP Practice Profiles Co-ordination, planning and monitoring of the implementation of NICE and other best practice guidance in Croydon The public health team will provide a consistent presence at the following meetings: o CCG Management Team (DPH or deputy) o CCG Governing Body (DPH or deputy) o CCG Clinical Leadership Group (Deputy DPH) o CHS CQR (nominated consultant in public health) o Primary Care CQR (nominated consultant in public health or agreed deputy) o Croydon Prescribing Committee and its subgroups (NICE; New Drugs) (DPH or deputy) o QIPP Operational Board (nominated consultant or agreed deputy) Knowledge management support, including response to ad hoc small-scale data requests Task and Finish Projects supporting specific aspects of the service transformation programme etc Appendix 3 Data Requirements Access to pseudonymised 1 records from the following datasets will be required: 1. GP data for public health intelligence purposes 2. SUS data (A&E, inpatient, outpatient) 3. Breastfeeding prevalence data 4. Births data from maternity units/health visitors 5. ONS births and mortality files 6. Exeter flag 4s data 7. Terminations of pregnancy data 1 Pseudonymised in this context is used as a general term for data from which information that identifies individuals has been removed. 64

65 Appendix 9: Framework for Collaboration with SWL CCGS South West London Clinical Commissioning Groups Framework for collaboration June