NHS Canterbury and Coastal CCG Extraordinary Part 1 Governing Body Meeting

Transcription

1 NHS Canterbury and Coastal CCG Extraordinary Part 1 Governing Body Meeting Charles Dickens RoomAnn Robertson Centre55 London RoadCanterburyKentCT2 BHQ 6 July :00-6 July :00 Overall Page 1 of 87

2 AGENDA # Description Owner Time 0 Agenda CCCCG Agenda Part 1v7.doc Introduction and Apologies Feedback and Pre-submitted Questions Quorum Declarations of Interest Committee declaration report - Canterbury Financial Recovery and Transformation Plan FS and paper - Financial Recovery and Tra Appendix 1 - Financial Recovery and Tran Appendix 2 - Overview QIA- local Care v2.d Alliance and GP Incentivisation Scheme FS and Paper - Alliance Incentivisation.docx Sustainable Transformation Plan (STP) Budget Contribution FC - STP Budget Contribution.doc STP Budget Proposal.docx STP Budget ADDENDUM fina Constitutional Change FC and Report - Constitutional Changes.d Any Other Business Invitations for questions from members of the public on the current agenda Next Governing Body Meetings Closure of Part 1 Overall Page 2 of 87

3 INDEX CCCCG Agenda Part 1v7.doc Committee declaration report - Canterbury GB.pdf FS and paper - Financial Recovery and Transformation.doc Appendix 1 - Financial Recovery and Transformation.ppt Appendix 2 - Overview QIA- local Care v2.docx FS and Paper - Alliance Incentivisation.docx FC - STP Budget Contribution.doc STP Budget Proposal.docx STP Budget ADDENDUM financial breakdown by organisa FC and Report - Constitutional Changes.doc...85 Overall Page 3 of 87

4 Overall Page 4 of 87

5 EXTRAORDINARY GOVERNING BODY MEETING Part 1 Thursday 6 July am 1.00pm VENUE: Charles Dickens Room, Ann Robertson Centre, 55 London Road, Canterbury, CT2 8HQ AGENDA Paper Lead Time 124/17 Introduction and Apologies Verbal Chair 5 mins 125/17 Feedback and Pre-submitted Verbal Chair 10 mins questions 126/17 Quorum Verbal Chair 1 mins 127/17 Declarations of Interest Chair 1 mins DECISION/APPROVAL 128/17 Financial Recovery and To follow Nick Dawe 60 mins Transformation Plan 129/17 Alliance and GP Incentivisation To follow Nick Dawe 15 mins Scheme 130/17 Sustainable Transformation Plan Nick Dawe 10 mins (STP) Budget Contribution 131/17 Constitutional Change Anthony May 10 mins 132/17 ANY OTHER BUSINESS 133/17 Invitations for questions from Verbal Chair 10 mins members of the public on the current agenda 134/17 NEXT GOVERNING BODY MEETINGs Governing Body Meetings - All held at Thanington Neighbourhood Resource Centre, Thanington Road, Canterbury CT1 3XE, unless stated otherwise: Thursday 3 August am to 1.00pm Thursday 5 October am to 1.00pm Thursday 7 December am to 1.00pm Thursday 1 February am to 1.00pm 135/17 CLOSURE OF PART 1 Conduct of meetings in relation to attendance by members of the public: Members of the public are asked to note that the Governing Body meetings are meetings of a Committee held in public. They are not public meetings where members of the public can speak at any point. Agendas identify when the Chair will receive questions and comments from the public. For all other agenda items speaking rights are reserved to Governing Body members and agreed representatives sitting at CCCCG Agenda Part 1v7.doc Page 1 of 2 Overall Page 5 of 87

6 the table; members of the public should not speak or intervene in proceedings unless invited to do so. In all matters the Chair s decision is final. Written questions from the public: Any questions relating to Governing Body meeting papers which are received in writing three or more days in advance of the meeting will receive a verbal response at the meeting, and the response will be appended to the minutes of the meeting. Please send your question, along with a contact telephone number or address, to: NHS Canterbury and Coastal CCG Governing Body Clinical Chair Canterbury Council Building Military Road Canterbury Kent CT1 1YW Or via c4.ccg@nhs.net CCCCG Agenda Part 1v7.doc Page 2 of 2 Overall Page 6 of 87

7 Declaration of interests register: Canterbury GB This register details the current declarations of members (and attendees) of the committee/group. Representatives should declare their conflicts and these should be recorded within the minutes. Archived declarations are available on request. The CCG's standard approach to the management of conflicts is: declare, hold on register, actively manage when conflict arises. The Chair of the meeting has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate action to ensure it is managed. Where a conflict exists, it should be re-declared prior to the relevant agenda item, and the Chair should ensure members are aware of the management approach, and that it is clearly recorded within the minutes. If the Chair is conflicted, then the Vice Chair would assume this responsibility. If members are concerned that a conflict is not being appropriately managed, this concern should be raised, ideally during the meeting. The Head of Corporate Services, Anthony May, can provide specific guidance, and additionally, the CCG Audit Chairs have taken on the responsibility of Conflict of Interest Guardian: for NHS Ashford CCG this is Steve Salt, and for NHS Canterbury and Coastal CCG this is Jackie Bell. Firstname: Surname: Position Title: Interest: Type: Jackie Bell Lay Member, Canterbury and Coastal CCG 1 Nil Alison Brett Interim Chief Nurse Matthew Capper Director of Performance and Delivery/Company Secretary, Ashford CCG and Canterbury and Coastal CCG Committee declaration report - Canterbury GB.pdf 1 Nil 1 Governor of a Primary School in Canterbury Non-Financial Personal Interests 2 Wife is Speech and Language Therapist for EKHUFT Indirect interests NHS Ashford and NHS Canterbury and Coastal CCGs Page 1 of 8 Overall Page 7 of 87

8 Firstname: Surname: Position Title: Interest: Type: Alistair Challiner Secondary Care Clinician, Canterbury and Coastal CCG 1 Practice rights at BMI Somerfield Hospital, Maidstone Financial interest 2 Professional Advisor to Care Quality Commission (CQC) Non-Financial Professional Interests 3 Practice rights at Kent Institute of Medicine and Surgery (KIMS) Financial interest 4 Medical Advisor Tactical Medical Unit, Kent Police Financial interest 5 Lead Anaesthetist for ECT, Priority House Maidstone, KMPT Financial interest 6 Fellow Royal College of Anaesthetists Financial interest 7 Fellow Faculty of Intensive Care Medicine Financial interest 8 Consultant in Intensive Care and Anaesthesia, Maidstone and Financial interest Tunbridge Wells NHS Trust 9 Practice rights at Nuffield Hospital, Tunbridge Wells Financial interest Nick Dawe Chief Finance Officer 1 Nil Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 2 of 8 Overall Page 8 of 87

9 Firstname: Surname: Position Title: Interest: Type: Simon Dunn Clinical Governing Body Member, Canterbury and Coastal CCG (GP - Herne Bay) 1 Member of Individual Funding Request Panel Non-Financial Professional Interests 2 Spouse is Primary Care Quality Manager for West Kent CCG Indirect interests 3 Provides clinical advice to the triage service for SECSU Financial interest 4 Practice is member of Invicta Health CIC Financial interest 5 Member and shareholder of Herne Bay Ophthalmology Clinic and Financial interest Cataract service providing outpatient ophthalmology clinics and cataract services from Beltinge and Reculver Surgery 6 GP Training Programme Director employed by Health Education Financial interest England 7 Full time GP Partner, St Anne's Group Practice, Herne Bay Financial interest 8 Director of Herne Bay Integrated Health Ltd Financial interest 9 Director of Herne Bay Health Ltd Financial interest Lorraine Goodsell Transformation Programme Director, Ashford CCG and Canterbury and Coastal CCG 1 2 Nil Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 3 of 8 Overall Page 9 of 87

10 Firstname: Surname: Position Title: Interest: Type: Chris Healy Clinical Governing Body Member, Canterbury and Coastal CCG (GP in Ash/Sandwich) 1 Practice hosts Ultrasound Service Financial interest 2 Practice hosts Physiotherapy Service Financial interest 3 Wife is an independent Chartered Physiotherapist who works in the Financial interest Practice 4 Practice hosts Hearbase Financial interest 5 Practice has signed up to the Vanguard MCP Financial interest Simon Lundy GP/Clinical Quality Lead/Mental Health Lead Anthony May Head of Corporate Services, Ashford CCG and Canterbury and Coastal CCG 1 GP appraiser for NHS England 2 Member of the Kent Local Medical Committee 3 Partner at Newton Place Surgery, which provides the following services: Treatment room, shared care, musculoskeletal services, adult ADHD prescribing and monitoring, looks after GP admission beds and step down beds at Faversham Cottage Hospital 4 Practice is a member of Invicta Community Interest Company 5 Practice is part of the Encompass Integrated Care Organisation pathfinder 6 Partner Newton Place Pharmacy Financial interest 7 GP - Newton Road Surgery, Faversham Financial interest 1 Nil Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 4 of 8 Overall Page 10 of 87

11 Firstname: Surname: Position Title: Interest: Type: Bill Millar Chief Operating Officer, Ashford CCG and Canterbury and Coastal CCG 1 Wife works for One Healthcare Ashford Indirect interests 2 Wife works at Pilgrims Hospice Indirect interests Dan Moore Clinical Governing Body Member, Canterbury and Coastal CCG (GP - Faversham) 1 Practice has LES with CCG for over 75 care plans Financial interest 2 Adviser to Trojan Telecom on cardiac monitoring Financial interest 3 Employed by Health Education England as a GP trainer Financial interest 4 Employed by NHS England as a GP Appraiser Financial interest 5 Member of the Vanguard MCP Financial interest 6 Partner at Faversham Medical Practice Financial interest 7 Partner of Alcroft Medical Services LLP providing medical services Financial interest 8 Practice has LES with CCG for contraceptive services Financial interest 9 Practice has LES with CCG for shared care prescribing Financial interest 10 Practice has LES with CCG for treatment room services Financial interest 11 Practice has LES with CCG for warfarin monitoring Financial interest 12 Practice provides minor injury (MIU) services Financial interest 13 Rent a property from NHS Property Services Financial interest 14 Member of Kent LMC and have on one occasion lectured for them Non-Financial Professional Interests 15 Student at University of Kent Non-Financial Professional Interests 16 Practice has joint LES with Newton Place surgery for triaging Financial interest orthopaedic referrals Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 5 of 8 Overall Page 11 of 87

12 Firstname: Surname: Position Title: Interest: Type: Ana Paula Nacif Lay Member PPE, Canterbury and Coastal CCG 1 Independent Coach and Facilitator with Living Well CIC, which is a Financial interest delivery partner for Turning Point 2 Consultant/trainer with Social Enterprise Kent and former Financial interest Consultant/trainer with Red Zebra 3 Executive Coach with the NHS London Leadership Academy Financial interest Simon Perks Accountable Officer, Ashford CCG and Canterbury and Coastal CCG 1 Member of the Advisory Board, Transforming Systems (SHREWD) Non-Financial Professional Interests 2 Trustee of Pilgrims Hospice Non-Financial Professional Interests 3 Director and Trustee of Cantercare Ltd, registered charity no: Non-Financial Professional Interests Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 6 of 8 Overall Page 12 of 87

13 Firstname: Surname: Position Title: Interest: Type: John Ribchester Clinical Governing Body Member, Canterbury and Coastal CCG (GP - Whitstable) 1 GP Partner Whitstable Medical Practice Financial interest 2 Provider of GP enhanced services Financial interest 3 Member Kent Postgraduate Education Centre, Canterbury Non-Financial Professional Interests 4 Member Downs Syndrome Association Non-Financial Professional Interests 5 Member - NHS National Advisory Group for the MCP Voluntary Non-Financial Professional Contract Interests 6 External adviser to Transformatioal Advisory Group of National Non-Financial Professional Association of Primary Care (NAPC) Honorary Interests 7 Chair of the Encompass Strategic Alliance Board 8 Shareholder of Invicta Health CIC, Canterbury Financial interest 9 Chair and Clinical Lead of Encompass MCP Financial interest 10 Provider of community physical therapy services Financial interest 11 Provider of a range of community outpatient, diagnostic and day Financial interest surgery services 12 Provider of a level 3 minor injury unit Financial interest 13 Practice has signed up to the Vanguard MCP Financial interest 14 Part owner of Estuary View Medical Centre Financial interest 15 Part owner Chestfield Medical Centre Centre Financial interest 16 Honorary Director and Shareholder, Thorndene Ltd, Swingfield, Financial interest Dover 17 Kent Ambassador Non-Financial Personal Interests Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 7 of 8 Overall Page 13 of 87

14 Firstname: Surname: Position Title: Interest: Type: Jonathan Sexton Independent Member for Strategic Health Planning 1 Associate at the Centre for Research into Children and Families: Non-Financial Professional Canterbury Christchurch University Interests 2 Fellow of faculty of Public Health Non-Financial Professional Interests 3 Independent Chair - Standards Committee, Thanet District Council Non-Financial Professional Interests Extracted from central database: 30 June 2017 Updates to be recorded by administrator, reflected in minutes and ed to maureen.thomas1@nhs.ne t Committee declaration report - Canterbury GB.pdf NHS Ashford and NHS Canterbury and Coastal CCGs Page 8 of 8 Overall Page 14 of 87

15 Report to: Canterbury and Coastal CCG Governing Body Agenda Item: 128/17 (Part 1) Date of Meeting: 6 th July 2017 Title of Report: Author: Governing Body Sponsor: Action Required: Conflict of Interest: Finance and Transformation Plan Nick Dawe Chief Finance Officer Nick Dawe Chief Finance Officer Approval None Decision X Discussion/ Assurance Information NB Please note that the figures included in this paper and the supporting publications are still subject to final review and minor change and unless where otherwise indicated reflect the combined position of Ashford and Canterbury and Coastal CCGs. Any changes known before the meetings will be reported to the Governing Bodies. In addition, a set of figures pertinent to the individual CCG will be made available at the Governing Body meetings. Summary of Key Issues for discussion: In April, the Governing Body approved an Operational Plan and supporting Budget for 2017/18. The Operational Plan prioritised progress with delivering Local Care through an Alliance (with all health and social care providers) and improvements in NHS constitutional standard performance, specifically those associated with urgent care and cancer care. The Operational Plan was supported by a Budget that achieved the mandated financial targets. In reviewing progress with the planning and delivery of the Operational Plan in May, several areas of concern were identified the most important being: The QIPP programme required to deliver service transformation and financial balance was only partly defined. Contract disputes for 2016/2017 and 2017/18 were identified but had been paused for resolution until July. Management costs were above target with no plan to bring them back to target FS and paper - Financial Recovery and Transformation.doc Page 1 of 5 Overall Page 15 of 87

16 Other new operational and finance pressures had arisen since the formation of the Operational Plan, particularly the temporary Kent and Canterbury Junior Doctors move and the request for more financial support for the Kent and Medway STP. Reserve balances had improved as a result of a detailed budget review. This paper identifies how all the above issues can be addressed and how the Operational Plan and Budget for 2017/18 agreed in April can be delivered. Risks: There are several risks associated with financial recovery and transformation. Without action, the financial and operational pressures on the CCG will increase and in autumn this would lead to the risk of the abrupt cessation of community clinics and other such initiatives, a significant slow-down in elective activity and an abrupt reduction in the number of CCG staff. All the above measures would be detrimental to services and access to elective services in particular. The risk rating at the point of setting the plan is a probability of 5 and an impact of 5, 25 in total. With action, risks remain in delivering QIPP to plan and timetable (especially due to the scale of the change envisaged and its dependency on the actions of other partners), contract disputes may not be resolved as planned, there could be delays in delivering organisational change and management cost reductions, there may be other national or local pressures requiring responses and using the reserve headroom available. The risk rating at the point of setting the plan is a probability of 3 and an impact of 5, 15 in total. Detailed risk and mitigation plans will be produced on approval of this paper. The key to risk mitigation will be strong project management and incisive performance management. Recommendations: The Governing Body is requested to support the following amendments and improvements to the Operational Plan and supporting Budget for 2017/18: To support the revised QIPP Plan as summarised in this FS and paper - Financial Recovery and Transformation.doc Page 2 of 5 Overall Page 16 of 87

17 document with the aim of delivering transformative change covering frailty, long-term conditions and other aspects of urgent care over the next two years through a significant expansion in Local Care. To support the resolution of all 2016/17 and 2017/18 contract disputes (preferably through discussion rather than mediation and arbitration), without prejudicing the CCGs ability to take a strong performance stance in the future with providers and with the limited use of reserves. To support organisational change and management efficiencies, including reductions to services contracted from the CSU to allow management cost targets to be met within the next two years, without prejudice to the delivery of transformative change and with the use of limited reserves as necessary. To support the position that any unexpected and planned service pressure, e.g. the temporary junior doctor moves from the Kent and Canterbury Hospital are either funded by discrete funds made available (centrally) by the NHS or failing this are met by temporary reductions in the level of elective activity that can be afforded and delivered by the East Kent Health System. To support the delegations set out in the next steps section. The key next steps and associated delegations are shown below: Next Steps: To delegate to the Accountable Officer and his nominated Directors in discussion with the Clinical Chairs the responsibility to finalise the revised QIPP Plan no later than 31 st July 2017 with implementation from 1 st August 2017 and progress reports expected to be received by the Governing Body from August onwards. To delegate to the Accountable Officer and Chief Finance Officer the responsibility for resolving all existing contract disputes for 2016/17 and 2017/18, reporting back the final position in August To delegate to the Accountable Officer and his nominated Directors in discussion with the Clinical Chairs, the responsibility to finalise the required organisational and management change arrangements with consultation to take place in August/September and implementation to be completed no later than 31 st FS and paper - Financial Recovery and Transformation.doc Page 3 of 5 Overall Page 17 of 87

18 December To delegate to the Accountable Officer and his nominated Directors the responsibility for resolving the Kent and Canterbury service and financial pressure issue by 31 st July 2017 and report back to the Governing Bodies in August 2017 the terms of the resolution. To delegate to the Accountable Officer and Chief Financial Officer the ability to use reserves and make other appropriate changes to Budget to secure the objectives set out above. To delegate to the Accountable Officer and Chief Financial Officer the responsibility for submitting to NHS E an updated Financial Recovery Plan based on the actions identified above. Link to Previous Reports: Operational Plan and Budget 2017/18 Strategic Objective Link: Resources: Communications: Financial Approval Required: Delivery of NHS constitutional standards and mandatory financial targets. As determined in this paper Full cascade to Practices, staff, partner organisations and NHSE YES Impact Assessments: Yes No N/A Finance: Equality: Quality: X X X Publication: Part 1 Supporting Paper/Appendices: 1. Financial Recovery and Transformation Presentation 2. Quality Impact Assessment FS and paper - Financial Recovery and Transformation.doc Page 4 of 5 Overall Page 18 of 87

19 3. Equality Impact Assessment (to follow). Please note other material has been made available to the Governing Bodies to support the decisions in this paper however this is not disclosed at this stage in public as it either discloses the CCG s position in terms of commercial negotiations and contract disputes or contains pre-consultation speculative information around management costs and structures that potentially involve other organisations or individual circumstances FS and paper - Financial Recovery and Transformation.doc Page 5 of 5 Overall Page 19 of 87

20 Overall Page 20 of 87

21 Financial Recovery & Transformation Thursday 22 nd June 2017 Updated 29 th June 2017 with minor updates and redactions NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Appendix 1 - Financial Recovery and Transformation.ppt Page 1 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 21 of 87

22 Index (1) 1. Introduction 2. Objectives 3. Context 4. QIPP and Transformation 5. HRP Investments /17 Contract Disputes /18 Contract Disputes 8. Management Costs 9. Kent and Canterbury Moves Appendix 1 - Financial Recovery and Transformation.ppt Page 2 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 22 of 87

23 Index (2) 10. Overarching Financial Impact 11. Next Steps Appendix 1 - Financial Recovery and Transformation.ppt Page 3 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 23 of 87

24 1. Introduction (1) In April 2017 the Governing Bodies approved their 2017/18 Plans and supporting Budgets. The 2017/18 Plans prioritized; improvements in performance in respect of the NHS Constitutional Standards and STP aligned service transformation, enabled by the establishment of Accountable Care Organizations within an East Kent Accountable Care Partnership The 2017/18 Budget delivered financial balance with the required national and local contingency reserves protected Appendix 1 - Financial Recovery and Transformation.ppt Page 4 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 24 of 87

25 1. Introduction (2) In May 2017 the Governing Bodies reviewed the deliverability of the 2017/18 Plans in the light of an external QIPP review and other emerging pressures and inconsistencies. In summary the following concerns were identified: That the QIPP challenge to be met through service transformation, service improvement and the elimination of (inappropriate) variation was only partially supported by detailed action plans and that previous year s plan had only been delivered in part Appendix 1 - Financial Recovery and Transformation.ppt Page 5 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 25 of 87

26 1. Introduction (3) That Health Reform Panel (HRP) proposed QIPP investments could be covered by increased savings over and above the existing QIPP target, but some of these savings may not materialize or materialize with delay due to current waiting list numbers. That the 2016/17 contract dispute issues had only partly been provided for and the CCGs supporting case in the event of mediation and arbitration were incomplete. That the 2017/18 contract disputes (EKHUFT only) had no provision and assumed a full CCG win and that no supporting case in the event of mediation and arbitration had been completed Appendix 1 - Financial Recovery and Transformation.ppt Page 6 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 26 of 87

27 1. Introduction (4) That even allowing for justifiable and funded charge across to CCG programme budgets, that core management costs were in excess of given management cost targets and no plans existed to bring expenditure back in line with budget. That the forecast gross costs of providing support and contingent capacity for the temporary Kent and Canterbury Hospital moves was significant and growing with some elements of cost potentially being recurrent. That the reserves had been created to provide for national and local contingency requirements but little flexibility existed beyond this Appendix 1 - Financial Recovery and Transformation.ppt Page 7 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 27 of 87

28 1. Introduction (5) The updated financial summary of the challenge is tabled below. Total m Note QIPP 22.9 Unchanged HRP Investment 0.0 But up to 5.7m of investment risk if benefit delayed due to waiting lists Contract 16/ Unchanged Contract 17/ Excluding QIPP component Management Cost 3.4 Unchanged KCH Move 2.2 Optimistic run out profile actual cost to East Kent health system could double this figure Total 43.3 Previously 64.6m Appendix 1 - Financial Recovery and Transformation.ppt Page 8 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 28 of 87

29 1. Introduction (6) If the issues and risks were not to be promptly and adequately addressed it is probable that the following will happen: The imposition of a special measures regime by NHS England with strict central command and control measures. The imposition of a series of centrally determined service rationing initiatives. The cessation of most in-turn inpatient elective activity. The cessation of community clinic and other practice investments. The immediate shedding of CCG staff Appendix 1 - Financial Recovery and Transformation.ppt Page 9 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 29 of 87

30 1. Introduction (7) To retain local control of the issues and reflect primary care preferences the following actions were agreed as a result of the May Governing Body workshop. To bring forward a revised and prioritized QIPP plan that identified schemes and options that would meet the savings target in full allowing for requisite investment. To confirm in the light of the priorities of the QIPP plan the investment required to deliver the service transformation. To confirm the contract management strategy for 2016/17 contract disputes Appendix 1 - Financial Recovery and Transformation.ppt Page 10 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 30 of 87

31 1. Introduction (8) To confirm the contract management strategy for 2017/18 contract disputes. To bring forward proposals to ensure management costs were contained to target levels in a way consistent with STP, ACO and East Kent partnership expectations To bring forward proposals to contain and manage the costs of the temporary Kent and Canterbury Hospital moves. To review in detail all operational budgets and transfer any benefit to reserves To ensure that the submitted trajectories of improvement for constitutional standards correlate to the revised plans Appendix 1 - Financial Recovery and Transformation.ppt Page 11 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 31 of 87

32 2. Objectives The main objective of today s meeting is to agree in outline a revised 2017/18 Plan and supporting Budget, (noting the formal approval in public with appropriate equality and quality impact statements will take place in July). Governing Bodies will also need to be clear as to the next steps in terms of; planning, implementing and monitoring of delivery Appendix 1 - Financial Recovery and Transformation.ppt Page 12 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 32 of 87

33 3. Context (1) Before examining each of the proposals in turn it is useful to briefly consider the underlying reasons for the financial and operational challenges and the CCGs track record of QIPP delivery. In common with all the NHS, underlying levels of funding growth over the past four years have run at around the 2% per annum mark. STP modelling indicates that allowing for demographic growth, increased patient expectations and technological improvement, that cost growth will be in the order of 6% per annum Appendix 1 - Financial Recovery and Transformation.ppt Page 13 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 33 of 87

34 3. Context (2) QIPP (transformational and transactional) and provider CIP are expected to make up the funding gap and provide for other system investment and resolution of historic issues. The gap can often be larger than the 4% indicated as a result of central initiatives. For example in 2017/18 further net funding gaps have arisen because of: revisions to the acute tariff, changes to specialist commissioning arrangements, STP management cost contributions, NHS market rent adjustments and an instruction to set aside funds for GP forward view investments Appendix 1 - Financial Recovery and Transformation.ppt Page 14 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 34 of 87

35 3. Context (3) There are a few key figures and trends that may be helpful in understanding the challenge and previous responses to it as the financial gap that needs to be addressed this year reflects prior year achievement and under-achievement as well as new year issues. Spending on secondary care contracts has broadly reflected general growth expectations other than a marked investment in Mental Health in 2016/17 (as a result of arbitration) and in Community Services in 2017/18, to prepare for local service transformation Appendix 1 - Financial Recovery and Transformation.ppt Page 15 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 35 of 87

36 3. Context (4) Spending on community clinics and placements has grown significantly over the period and funding has of course been provided and diverted to the Better Care Fund. There is no specific evidence suggesting that the general approach to contract management and contract renegotiation has been flawed though a more detailed review of changes over time may e helpful in future contract management discussions Appendix 1 - Financial Recovery and Transformation.ppt Page 16 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 36 of 87

37 3. Context (5) QIPP is in essence the gap between available funds and committed costs, QIPP is delivered by either agreeing reductions in contracts or by delivering service improvements that reduce the level of chargeable activity. If changes in contract values are agreed as part of the annual contract management process sometimes this is included in QIPP and sometimes excluded from QIPP (but with the gain included in the bottom line). QIPP targets over the past four years have ranged between 2 and 5% of turnover with actual achievement against target ranging from as low as 34% in Canterbury last year to 87% in 2014/ Appendix 1 - Financial Recovery and Transformation.ppt Page 17 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 37 of 87

38 3. Context (6) Appendices attached for further reference are: 3.1 Spend history Ashford 3.2 Spend history Canterbury 3.3 QIPP history Ashford 3.4 QIPP history Canterbury 3.5 Management cost trends Ashford 3.6 Management costs trend Canterbury Appendix 1 - Financial Recovery and Transformation.ppt Page 18 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 38 of 87

39 4. QIPP and Transformation (1) The attached presentation at 4.1 reviews the opportunities for QIPP saving building upon the existing local plans for; managed service access, long-term conditions and reducing variation. In addition to these initiatives the presentation looks at the opportunities to push further on existing initiatives and in particular address issues of frailty, reducing nonelective admissions and reducing accident and emergency attendances Appendix 1 - Financial Recovery and Transformation.ppt Page 19 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 39 of 87

40 4. QIPP and Transformation (2) Please refer to attached presentation Appendix 1 - Financial Recovery and Transformation.ppt Page 20 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 40 of 87

41 4. QIPP and Transformation (3) Attention is drawn to the following issues arising from the presentation. That the scheme requires radical service change at pace, ideally on a coordinated East Kent basis. That current work priorities will need some reordering so that the key issues are addressed in the right order based on operational sense and net financial return. That in 2017/18 there is a shortfall of 8.1 on the QIPP target and how this can be managed needs discussion Appendix 1 - Financial Recovery and Transformation.ppt Page 21 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 41 of 87

42 5. HRP Investments (1) The attached appendix at 5.1 was reviewed at the previous meeting and still stands. However the following issues need to be considered: That the proposals, sequencing and timing still stands in the light of the QIPP and Transformation presentation. That investment would only be releasable as and when progress with the QIPP programme was to target and if applicable, EKHUFT had agreed to manage waiting lists in line with revised CCG waiting list trajectories and or hold lists at current size Appendix 1 - Financial Recovery and Transformation.ppt Page 22 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 42 of 87

43 /17 Contract Disputes (1) To defend the financial position of the CCGs an aggressive approach to contract disputes occurred at the end of the previous financial year. To date no issues have been resolved and the net risk is 8.2m. Taking due account of the relative strength of the CCGs argument and the broader perspective on joint working it is proposed that the CCG moves to a position as detailed on the next page that would be a 4.2m call on reserves and assumes all remaining debt can be defended Appendix 1 - Financial Recovery and Transformation.ppt Page 23 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 43 of 87

44 /17 Contract Disputes (2) Issue Net Value m Settle Value m KMPT (includes old items) 0.7 KCHFT 0.5 CSU 0.4 SKC CCG 1.0 EKHUFT PbR out-turn 4.4 EKHUFT HSCV beds 0.5 Healthcare at home (old) 0.3 FP10 Sussex Care (old) 0.4 Total Appendix 1 - Financial Recovery and Transformation.ppt Page 24 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 44 of 87

45 /18 Contract Disputes (1) The 2017/18 contract disputes relate entirely to EKHUFT and reflect the issues outstanding at contract signature that were judged to be 50:50 calls. The CCGs current position is that all disputed items should fall entirely to the CCG s favour. To date no issues have been resolved and the net risk excluding QIPP and QIPP investment for 2017/18 is 6.6m The disputed items are tabled on the next page Appendix 1 - Financial Recovery and Transformation.ppt Page 25 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 45 of 87

46 /18 Contract Disputes (2) Item Value m Out-turn gap /18 QIPP FYE 0.6 Homecare drugs 0.5 Paediatric assessment investment 0.4 Community paediatric investment 0.5 Phlebotomy to practices 0.1 Sleep studies 0,4 Total Appendix 1 - Financial Recovery and Transformation.ppt Page 26 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 46 of 87

47 /18 Contract Disputes (3) At this stage it is not intended to concede on any of the items and they remain a risk. The out-turn activity value will become an undeniable fact shortly but all other items are speculative. NHS England and NHS Improvement wish to resolve any remaining 2016/17 and 2017/18 contract disputes before the end of July Appendix 1 - Financial Recovery and Transformation.ppt Page 27 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 47 of 87

48 /18 Contract Disputes (3) At this stage it is not intended to concede on any of the items and they remain a risk. The out-turn activity value will become an undeniable fact shortly but all other items are speculative. NHS E and NHS I wish to resolve any remaining 2016/17 and 2017/18 contract disputes before the end of July Appendix 1 - Financial Recovery and Transformation.ppt Page 28 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 48 of 87

49 8. Management Costs (1) The management costs of the CCG (both core and programme) have grown over tome with particular impetus for that growth occurring after investment in the nursing and quality team and in respect of cocommissioning. Another factor preventing flexibility is that the CSU charges that represent some 50% of the management cost have been to date, considered as fixed. It is proposed to bring management costs down to budget through a restructuring reflecting East Kent working and the development of Accountable Care Organisations Appendix 1 - Financial Recovery and Transformation.ppt Page 29 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 49 of 87

50 8. Management Costs (3) Attention is drawn to the following issues. Firstly it remains unclear as to whether the proposal will be accepted across East Kent and if implemented will yield the savings required in year. Secondly the proposal will have costs of change yet to be determined in terms of retraining, redundancy and other items. Some more incremental savings are possible through non-filling of vacancies and negotiating reductions in CCG charges in-year Appendix 1 - Financial Recovery and Transformation.ppt Page 30 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 50 of 87

51 9. Temporary Kent and Canterbury Moves (1) The temporary Kent and Canterbury Hospital moves have added a further financial burden to the health economy that is likely to fall within the range 2.2m to 4.4m. Although there is general acknowledgement that service disinvestment may be required to offset this cost no firm plans to do this are in existence. The current plan does not, at an operational level, include the managed run-out of the contingency arrangements including the additional capacity Appendix 1 - Financial Recovery and Transformation.ppt Page 31 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 51 of 87

52 10. Overarching Financial Impact (1) It is accepted that work remains to be done in refining the proposals set out in this paper and that this will need to be concluded urgently. If however the proposals are set out as agreed and the working assumptions around risks hold the summary financial recovery position across both CCGs will be as shown in the table overleaf Appendix 1 - Financial Recovery and Transformation.ppt Page 32 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 52 of 87

53 10. Overarching Financial Impact (2) Pessimistic Presentation Initial Gap m Gap After Plan m Gross Residual Risk m QIPP HRP Investment Contract 16/ Contract 17/ Management Cost KCH Move Total Reserves (useable) Grand Total Appendix 1 - Financial Recovery and Transformation.ppt Page 33 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 53 of 87

54 10. Overarching Financial Impact (2) Optimistic Presentation Initial Gap m Gap After Plan m Gross Residual Risk m QIPP HRP Investment Contract 16/ Contract 17/ Management Cost KCH Move Total Reserves (useable) Grand Total Appendix 1 - Financial Recovery and Transformation.ppt Page 34 of 34 NHS Ashford Clinical Commissioning Group NHS Canterbury and Coastal Clinical Commissioning Group Overall Page 54 of 87

55 Overview Quality impact delivery of local care model at scale and pace The Local care model incorporates a number of schemes aiming to provide more benefits for patients; avoid hospital stays; increase partnership working; develop the local workforce; enable more self-care and improve urgent care for > 70yrs and for those with complex health and care needs. Duty of Quality Could the proposal impact positively or negatively on any of the following - compliance with the NHS Constitution, partnerships, safeguarding children or adults and the duty to promote equality? Potentially positive impact on partnerships. Increased staffing and supply with higher retention of health and care professionals across systems - positive Negative- However due to the proposed scale and pace there could be a risk that not all partners work to the same timescales leaving gaps in patient pathways. Gaps in pathways could lead to suboptimal care. Patient Experience Could the proposal impact positively or negatively on any of the following - positive survey results from patients, patient choice, personalised & compassionate care? Negative-Patient consultation has not been fully achieved on local care initiatives. Recommend patient surveys undertaken of new service delivery. Healthwatch with clear comparable measurable outcomes Positive -Closer to home with provision of care from effective facilities i.e increased care in community and fewer unnecessary Hospital admissions. Joined up services with healthcare professionals acting as a single team Patient Safety Could the proposal impact positively or negatively on any of the following safety, systems in place to safeguard patients to prevent harm, including but not exclusively infections? Negative-Concerns re pace and scale of change to patient pathways Positive-Improved clinical outcomes less harm due to bed based care, improved targets on investigations, patients healed faster and more effectively. Reduced length of stay in both acute and local settings 29/6/17 Quality Team NHS Ashford and Canterbury Clinical Commissioning Groups Appendix 2 - Overview QIA- local Care v2.docx Page 1 of 2 Overall Page 55 of 87

56 Clinical Effectiveness Could the proposal impact positively or negatively on evidence based practice, clearly defined clinical outcomes, clinical leadership, clinical engagement and/or high quality standards? Positive outcomes are predicted but will need monitoring. Co-location of multi-disciplinary teams and faster and better clinical decision making aims to improve clinical outcomes. System wide processes streamlined to provide higher quality service at lower cost. Clinical engagement is crucial to ensure the effectiveness of a new service and the facilitation of the change. The lack of sustainable workforce modelling / insufficient skill mix across the primary care workforce may pose a risk to delivery- to mitigate work should align to the workforce strategy and action plan for our CCGs which we are currently aligning with the CEPN work streams across East Kent Prevention Could the proposal impact positively or negatively on promotion of self-care and health inequality? Healthier population with improved quality of life with reduced need for health and care services positive Potential to reduce inequalities for populations, working in ways which reflect local needs and local circumstances - positive positive Productivity and Innovation Could the proposal impact positively or negatively on - the best setting to deliver best clinical and cost effective care; eliminating any resource inefficiencies; low carbon pathway; improved care pathway? Flexibility of mobile working for staff - higher retention of health and care professionals with a greater skills based workforce to support the needs of local population positive 29/6/17 Quality Team NHS Ashford and Canterbury Clinical Commissioning Groups Appendix 2 - Overview QIA- local Care v2.docx Page 2 of 2 Overall Page 56 of 87

57 Report to: Canterbury and Coastal Governing Body Agenda Item: Date of Meeting: 6 th July 2017 Title of Report: Author: Governing Body Sponsor: Canterbury and Coastal CCG Vanguard Alliance Next Steps Nick Dawe, Chief Financial Officer Molly Walsh Kearney Executive Assistant Nick Dawe, Chief Financial Officer Action Required: Approval Decision X Discussion/ Assurance Information Conflict of Interest: None Key Issues In the Operational Plan for 2017/18 and the supporting Budget for 2017/18, the development of an alliance approach to strengthen primary care and deliver a wider range of local services was a key funded priority. Summary of Key Issues for discussion: As a necessary prerequisite for the strengthening of the capacity and capability to deliver local care work has been undertaken to incentivise individual practices to collaborate, work at scale and develop the range of local service offerings as well as improving access, in line with the published NHS GP Forward View Plans. This report concerns itself with the release of the investment set aside to fund and incentivise these changes that will allow the operational plan and priorities to be delivered. This proposal applies to the Encompass Vanguard and Herne Bay group of practices. Similar proposals are intended for Ashford CCG FS and Paper - Alliance Incentivisation.docx Page 1 of 7 Overall Page 57 of 87

58 Background and Context The Encompass Vanguard has been developing an out of hospital care model for the last two to three years for Canterbury, Whitstable, Faversham, Sandwich and Ash. The Encompass model has contributed to the development of the Local Care model that has been developed across Kent and Medway as part of the Sustainability and Transformation Plan (STP). Local Care models have also been in development in both Herne Bay and Ashford and these are also now being informed by the direction provided by the STP. Encompass have developed a detailed work plan for this year (2017/18) and have started to develop a Strategic and Operational Alliance with the main providers in East Kent to deliver this work plan (The Encompass Alliance). Herne Bay Integrated Care Ltd is leading development of the local care model in Herne Bay, they are working closely with Kent Community Health NHS Foundation Trust (KCHFT). The Herne Bay model is being developed based on a detailed phased work plan incorporating both minor injuries/ urgent care development and local care (The Herne Bay Alliance). Risks: That the required targets may not be fully met and/or met to time, causing delays in delivering the operational and clinical benefits required. This may in turn lead to delays in delivering the Local Care Model and the service and financial improvements associated with it. As the aim of the incentivisation scheme is to reward achievement the risks are considered as a low probability (one) but with a high impact (five) giving a risk rating of (five), within the risk appetite of the Governing Body. Recommendations: Next Steps: That the incentivisation approach and payments as described are approved with delegations as set out in the section Next Steps. 1. Validate phase 1 and phase 2 targets and produce a check list for approval (by 31 st July 2017), Transformation Programme Director 2. Confirm achievement of phase 1 targets having been met (by 30 th September 2017), Transformation Programme Director in discussion with Clinical Chair. 3. Confirm achievement of phase 2 targets having been FS and Paper - Alliance Incentivisation.docx Page 2 of 7 Overall Page 58 of 87

59 met (by 28 th February 2018), Transformation Programme Director in discussion with Clinical Chair. Link to Previous Reports: Strategic Objective Link: Resources: Communications: N/A Local Care Development and Financial Recovery Plan As specified A communication will be sent to all practices following Governing Body decision. Alliance partners will be notified of this arrangement as will the NHS E New Models of Care Team. Financial Approval Required: Yes X No Impact Assessments: Yes No N/A Finance: Equality: Quality: Publication: Restriction (define) X X X No Restriction X Supporting Paper/Appendices: Annual Budget 2017/18, Operational Plan 2017/ FS and Paper - Alliance Incentivisation.docx Page 3 of 7 Overall Page 59 of 87

60 1. Introduction To combat the increasing and significant pressures on the health and social care system as a result of demographic changes, an ageing population, rising expectations, and flat funding, the NHS Five-Year Plan and Sustainability and Transformation Plans have been developed. The Kent and Medway STP is designed to bring the increase in demand and expectation in line with supply of services, and the three key areas are centred around the whole population living healthier lifestyles, with the promotion of good health rather than the treatment of ill-health, alongside the shift of patient care out of acute hospitals and into a home setting. In line with the Local Care approach, out of hospital health, social and wellbeing services are best provided based around GP practices (with community, social and third sector support), enabling enhanced patient care decision making and better demand management. The Vanguard Alliance and similar arrangements in Herne Bay, allows delivery of strategic aims to improve health and well-being via collaborative local working. The Vanguard Alliance has existed for more than two years as a project, developing and testing New Models of Care. It has now grown to take into account wider Kent and Medway Sustainability and Transformation Plans and the GP Five-Year Forward View. The vision is to provide high quality, outcome focused, person centred, coordinated care that is easy to access and that promotes wellness for people to live independently for as long as possible. Whole system redesign at an organisational level, working in collaboration across the health and care landscape, will enable the building and implementation of an innovative, integrated workforce working across professional boundaries. There is a preliminary requirement to make an Accountable Care Organisation (ACOs) work; the appropriate service transformation is to deliver Primary Care arrangements and to encourage collaborative behaviours to ensure high standards of quality are delivered. 2. Development of a Funding Approach to ACOs Work continues around the formation of a capitation approach that would support the future service contracts with ACOs. As part of the overall approach it is proposed that incentivisation payments are an appropriate way of encouraging service transformation and delivery. This has already been built into all major service contracts with Trusts. It is now proposed that this approach be introduced into Primary Care to facilitate collective working. The logic of incentivising transformation is to ensure all parties engaged in the transformative change are encouraged for delivering either to, or ahead of an agreed plan. The logic of incentivising transformation is basically to ensure that both the gainers and losers arising from the change are rewarded for delivering to or ahead of plan, with plans having a simple but balanced set of outcomes centred on improving; value, i.e FS and Paper - Alliance Incentivisation.docx Page 4 of 7 Overall Page 60 of 87

61 effectiveness, efficiency and economy. Some attributes of transformation that could be incentivised singularly or collectively are as follows: Positive attributes to be accentuated:- Improvements in the clinical effectiveness of the system / service / intervention Improvements in the cost effectiveness of the system / service / intervention Improvements in whole population health Improvements in access Improvements in choice Improvements in patient and / or staff satisfaction Delivery of improvements ahead of schedule. Delivery of improvements at a scale greater than planned Behavioural improvements, e.g. constructive alliance working Reduced costs of transformation and change. Potentially there are negative attributes that may need to be avoided or mitigated and these could include:- Guard against unilateral action by one party Guard against a provider loading the costs of change Guard against a provider frustrating change, e.g. by an unwillingness to share assets or information. The plan seeks improvement in outcomes and public and staff satisfaction delivered through an evidence based approach centred on effectiveness, efficiency, and economy. Improvements could be seen in the clinical and cost effectiveness of the system, better access and choice, augmented whole population health, and patient and staff satisfaction. Incentivisation may also result in the delivery of improvements ahead of schedule and at greater scale, more constructive Alliance working, and reduced costs of transformation. Possible negative risks to be mitigated include guarding against unilateral action by one party, provider loading cost of change, or a provider frustrating change. 3. Detail of Incentivisation It is proposed that for Primary Care the incentivisation scheme will have two phases in the first instance; the first to encourage collective and open working between and across practices, the second part is linked to the delivery of the GP Forward View expectation of improved access and service quality. Phase One The first phase of incentivisation will encourage the ability to quantify the pressure on general practice and to demonstrate the contribution being made by individual practices in terms of availability of appointments. It is proposed that a system of live electronic feeds from the appointment module of EMIS. Such live feeds can record indicators such as FS and Paper - Alliance Incentivisation.docx Page 5 of 7 Overall Page 61 of 87

62 availability of GP and nurse appointments, number of patients seen, diagnosis codes, number of urgent referrals to secondary care per speciality. This information can be collated into dashboards for GPs. By providing this information, practices can contribute to describe the genuine pressures on general practice and therefore the need for investment. Provision of these live feeds should require no extra effort by practices beyond ensuring that appointment data is recorded in a consistent way across practices. Based on evidence from elsewhere in England and abroad, it is reasonable to be cautiously optimistic that successful implementation of local care in Hubs will reduce the demand on and cost of urgent secondary care facilities. This is particularly desirable in East Kent as the future sustainability of EKHUFT depends on a strategy of reducing the bed stock significantly. This cannot happen unless demand is reduced by Encompass and other similar initiatives in the other three CCG areas of East Kent. It has been agreed in principle that a proportion of any savings in urgent and elective secondary care can flow to general practices in recognition of the part they play in reducing costs. Initiatives such as improved access, local care but also extended general practice to include paramedic practitioners, increased use of GPs with Special Interests social prescribing and other initiatives should all contribute to this saving. Phase 2 The GP Five Year Forward View calls for better integration of GP, Community, Mental Health, and Social Care to improve prevention and care for patients. It recognises that those areas ready to go further in fully integrating their services and funding, using the formation of ACOs to achieve better outcomes in the identified five priority areas, will receive backing. A number of focused actions to remove strain and improve performance in A&E, Cancer, GP Access, Mental Health, and the Frail and Elderly are identified in the GP Forward View, and collaborative working across services is imperative for success. 4. Funding Proposal The value of services being transformed in the Canterbury and Coastal CCG area in 2017/18 is circa 10m (though this could significantly increase as part of the Financial Recovery and Transformation Plan). Phase per head of population served by GPs associated with working collectively, improving integration, and sharing information throughout the ACO, fuller development of working collectively at scale with CHOCs and MDTs to improve access and quality. This section concerns working with all other health and social care providers at a population level of 30,000-50,000. CHOCS rely on GP input for success and the concept of individual practices working collaboratively to develop local care is fundamental of this funding is nonrecurrent. With a registered Canterbury CCG population (including Herne Bay) of 218,664, this gives a gross figure of 983, FS and Paper - Alliance Incentivisation.docx Page 6 of 7 Overall Page 62 of 87

63 Phase 2 A further 3.00 per head of population risk and reward payment based on delivering and exceeding transformation targets set in line with the GP Forward View, with values being variable and payment being made in arrears, i.e. early in the financial year following the financial year of delivery. With a registered Canterbury CCG population (including Herne Bay) of 218,664, this gives a gross figure of 655,992. Phase 3 Would involve all Alliance members sharing any net gain or loss on the broader application of funds for sources. This does not form any part of the decision being made today. 5. Timing and Distribution of Funding Funding would be paid to the collective entity of the GP Vanguard and GPs in Herne Bay (for onward distribution to individual practices in a way that recognises costs, effort, achievement and risks and complies with value for money test for public spending). The proposed distribution timescales for the above funding is as follows: 4.50 per head of population (Phase 1) to be delivered in full for the end of September 2017 to the appropriate GP collective body. A further 3.00 per head of population (Phase 2) proposed to be delivered around the end of February 2018 based on satisfactory progress with improving access to services to the appropriate GP collective body. 5. Governance The detailed list of targets and measures for measuring and assessing delivery of these targets will be delegated to the Transformation Programme Director in discussion with the Clinical Chair with all arrangements complying with the Standing Orders and Standing Financial Instructions of the CCG. 6. Recommendation To support the operation of the GP incentivisation scheme as set out in sections 3, 4, and 5 for the 2017/18 financial year FS and Paper - Alliance Incentivisation.docx Page 7 of 7 Overall Page 63 of 87

64 Overall Page 64 of 87

65 Report to: Canterbury and Coastal CCG Extraordinary Governing Body Agenda Item: 130/17 Date of Meeting: 6 July 2017 Title of Report: Author: Governing Body Sponsor: Kent and Medway STP Budget Proposal Michael Ridgwell - Programme Director Kent and Medway Sustainability and Transformation Plan Nick Dawe Chief Finance Officer Action Required: Conflict of Interest: Approval Decision Discussion/ Assurance None X Information This paper outlines the STP budget proposal for 2017/18 that has been discussed and supported by the STP Programme Board. The paper defines the resource requirement that has been identified and how it is proposed to be met by contributions from STP member organisations. The STP is a vehicle for co-ordinated strategic planning and strategic decision making and facilitating the development of clinically led service transformation and capital proposals. Summary of Key Issues for discussion: The STP is at the point of converting its role from being focused on co-ordination to a role with additional command and control capacity. This change together with the need to deliver detailed business cases to allow decisions to be made on clinical transformation and public consultation are the key drivers for cost. The STP Programme Board agreed to the budget in principle, subject to approval by respective governing bodies and committed to seeking formal approval. An addendum to the paper is included, outlining the financial breakdown by organisation based on the composite methodology proposed in the budget paper. Risks: The proposed 637,674 contribution from the CCG is significantly higher than the budgeted 300,000 and in addition the CCG is already significantly above its management cost target FC - STP Budget Contribution.doc Page 1 of 3 Overall Page 65 of 87

66 The Governing Body should support the proposal but with the following provisos and suggestions to the STP Programme Board, via the Programme Director. That the STP Programme Board should use secondment and virtual teams in preference to additional recruitment and/or the use of consultants. That the STP Programme Board should set specific returns on this investment in terms of reducing the existing management burdens on CCGs, ensuring the delivery of business cases more effectively and to a tighter timescale than currently planned. This may allow some or all of the cost to be capitalised. Recommendations: That the STP Programme Board should provide monthly progress and return on investment reports to Governing Bodies (and Trust Boards). That the STP Programme Board should clearly understand that the contribution will not be considered a management cost and count against the management cost target (and gain NHS E support for this stance). That the STP Programme Board should clearly understand that the funding of this investment will require the clawback and use of the 0.5% CQINN funding set aside for STP related initiatives, i.e. it will be spent on management costs not service or qualitive improvements. Next Steps: Feedback to STP Programme Director Link to Previous Reports: Strategic Objective Link: Resources: Communications: Financial Approval Required: Governing Body Committee papers 8: Ensuring a sustainable financial future and good governance. NA NA YES FC - STP Budget Contribution.doc Page 2 of 3 Overall Page 66 of 87

67 Impact Assessments: Yes No N/A Finance: X Equality: Quality: X X Publication: Yes Supporting Paper/Appendices: 1. STP Budget Proposal (2017/18) 2. Addendum: financial breakdown by organisation FC - STP Budget Contribution.doc Page 3 of 3 Overall Page 67 of 87

68 Overall Page 68 of 87

69 Introduction KENT AND MEDWAY SUSTAINABILITY PARTNERSHIP STP Budget Proposal 1. This paper outlines the Kent and Medway Sustainability and Transformation Partnership (STP) budget proposal for 2017/18. The STP Programme Board is asked to approve this paper and the constituent organisations are asked to make available the identified budget. 2. The paper builds on information already presented to the STP Programme board and is constructed against the key considerations outlined in HM Treasury s Five Case Model. Context 3. Sustainability and Transformation Plans were proposed in the annual NHS planning guidance Delivering the Forward View: NHS planning guidance 2016/ /21 issued in December This outlined the triple aim of the plans was to address: health inequalities; quality failings and under-performance against NHS Constitution targets; and financial challenges. 4. The further development of Sustainability and Transformation Plans, and a further recognition that these arrangements are about collective system leadership through the change of name to Sustainability and Transformation Partnerships, was outlined in Next Steps on the Five Year Forward View 2 published in March Further information on the strategic intent of the Kent and Medway STP is included in the section of this paper outlining the strategic case. However, the objectives for the STP for 2017/18, that support the delivery of the triple aim outlined in Point 3, have been identified as: East Kent system changes and completing consultation at the earliest possible juncture; Stroke and vascular redesign, including reaching consultation where required; Local Care both to ensure the sustainability of primary care, integrate mental and physical health, and as an enabler of the overall ambition of the STP; Delivering financial sustainability through productivity savings; System / commissioning development: including the development of new commissioning arrangements and the development of accountable care organisations / systems; Winter / seasonal planning for 2017/ VIEW.pdf STP Budget Proposal.docx 1 Page 1 of 14 Overall Page 69 of 87

70 Process for identifying the 2017/18 STP budget 6. As outlined in the Kent and Medway STP submission made to NHS England and NHS Improvement in October a programme approach has been adopted to deliver the STP as outlined in the following governance structure: Governance group Provider CEs Commissioner AOs Medway, North & West Kent Delivery Board East Kent Delivery Board Provider Boards PMO CCG Gov. Bodies Programme Board HWB(s) LA Cabinets Management Group No decision-making authority Delivery board Delivery group Partnership Board Patient and Public Advisory Group (PPAG) Clinical Board Finance Group Care Transformation Enablers Productivity System Leadership Case for change Prevention Local care Hospital care Mental Health Workforce Digital Estates Productivity Including: Shared back office Shared clinical services Prescribing Commissioning Transformation Comms and engagement Source: Kent and Medway STP 7. The thirteen workstreams within the agreed programme structure are working to deliver agreed deliverables against the overall programme plan. Each workstream has considered the resource requirements needed to enable them to successfully achieve their deliverables. In addition, costs of a central STP leadership team and internal programme management office (PMO) have been identified. The development of the internal PMO would enable the STP to move away from its current reliance on the provision of programme support from its external partner and enable external support to be focused around providing specialist and technical support to key areas of the programme. 8. The resource requirements were scrutinised through check and challenges sessions. The sessions were conducted by convening an STP leadership panel of NHS and local authority leaders drawn from the four STP oversight groups (e.g. the Programme Board, Management Group, Clinical Board and Finance Group). The panel met with members of each workstream and discussions were structured around four thematic questions: i. What progress have you made to establish a baseline position across Kent and Medway, and to identify key opportunities for improvement? ii. iii. What progress have you made to design and quantify the future state for Kent and Medway? What is the forward plan (including resourcing)? STP Budget Proposal.docx 2 Page 2 of 14 Overall Page 70 of 87

71 iv. How is your workstream engaging with the wider STP, system leaders, clinicians, staff and the public? 9. The check and challenge sessions also supported the programme team to confirm the interdependencies between the workstreams and the impact of de-prioritising particular areas of work. As anticipated this demonstrated that all workstreams are key to the delivery of the objectives stated in the introduction to this paper. Attachment 1 outlines summary information from the check and challenge sessions, including the consequence of not progressing the work being undertaken by individual workstreams. Budget proposal 10. Based on the workstream resource requirements and the costs of the STP leadership team and PMO, the following resource requirement has been identified: Sum of Q1 Sum of Q2 Sum of Q3 Sum of Q4 Projected 17/18 Programme '000 '000 '000 '000 '000 Hospital Care ,879 Local Care ,481 Project Management Office Project Management Office - EK STP Leadership Productivity ,295 Communications Communications - EK PPAG (support from H/watch) Commissioning / System Transformation ,305 Accommodation Legal Fees Urgent Care Workforce Mental Health Estates Workstream Digital Contingency Income (NHS 80k / HEE 350k) Grand Total 2,363 3,051 2,713 2,283 10, The 10.4m resource requirement identified in the above is consistent with the initial appraisal of the costs required to deliver the STP change programme, which was originally identified and described in the first STP draft submission made to NHS England in June STP Budget Proposal.docx 3 Page 3 of 14 Overall Page 71 of 87

72 Strategic case - is the proposed investment supported by a compelling case for change 12. The Kent and Medway STP Clinical Board have prepared a technical case for change 4 which has been used to prepare a more accessible public facing case for change to support engagement with stakeholders These documents outline the strategic rationale for why change is needed. Whilst there is much to be proud of about health and social care services in Kent & Medway there are several issues that we need to tackle; there are long waiting times for some services and the quality of care is not always as good as it could be. We also need to focus on reducing the need for health and social care, through self-management, ill health prevention and earlier diagnosis. The following provides a summary of the case for change: Health and wellbeing Quality of care Sustainability Case for change Our ambition Our population is expected to grow by 414,000 people by Growth in the Create services which are able to number of over 65s is over 4 times greater than those under 65; an aging meet the needs of our changing population means increasing demand for health and social care. population There are health inequalities across Kent & Medway; in Thanet, one of the most deprived areas of the county, for example, a woman living in the best ward for life expectancy in Thanet can expect to live almost 22 years longer than a woman in the worst. The main causes of early death are often preventable. Over 500,000 local people live with long-term health conditions, many of which are preventable. And many of these people have multiple long-term health conditions, dementia or mental ill health. There are over 1,000 people who are in hospital beds who could be cared for elsewhere if services were available. Being in a hospital bed for too long is damaging for patients and increases the risk of them ending up in a care home. We are struggling to meet performance targets for cancer, dementia and A&E. This means people are not seen as quickly as they should be. Many of our local hospitals are in special measures because of financial or quality pressures and numerous local nursing and residential homes are rated inadequate or requires improvement. Our workforce is ageing and we have difficulty recruiting in some areas. This means that senior doctors and nurses are not available all the time and there are high numbers of temporary staff across health and social care. Reduce health inequalities and reduce death rates from preventable conditions More measures in the community to prevent and manage long-term health conditions Make sure people are cared for in clinically appropriate settings Deliver high quality and accessible social care across Kent and Medway Reduce attendance at A&E and onward admission at hospitals Support the sustainability of local providers We are 110m in the red and this will rise to 486m by 20/21 across health Achieve financial balance for and social care if we do nothing. health and social care across Kent and Medway To attract, retain and grow a talented workforce SOURCE: Kent and Medway 5yrFV 14. The position outlined in the case for changes provides further details of the challenges against the triple aims of STPs as outlined in Point 3, namely: health inequalities there continue to be significant health inequalities within Kent and Medway, with the main causes of early death often being preventable: quality failings and under-performance of NHS Constitution targets with large numbers of patients not supported in the most appropriate setting of care, widespread non-delivery of NHS Constitution targets and a significant number of organisations facing quality challenges; and financial challenges a net over-performance on 110m in 2015/16 on the NHS total system budget which is projected to rise to 486m by 2020/ FINAL-UPDATED.pdf 5 APRIL-17.pdf STP Budget Proposal.docx 4 Page 4 of 14 Overall Page 72 of 87

73 15. The challenges outlined above, and in more detail in the case for change, impact detrimentally on the health and lives of the population we service and on the sustainability of NHS and social care services. The strategic remit of the STP is to address these challenges. Point 5 outlines the strategic priorities being pursued by the STP in 2017/18. Economic case - does the investment option optimise value for money? 16. As outlined in the section of this document on the strategic case, the STP case for change identifies a significant financial challenge. The modelling work that supported the October 2016 STP submission 6 to NHS England led to the development of an outline financial plan that brings the system close to balance. The following waterfall, which was taken from the submission, outlines the key items that lead to the financial challenge outlined in the case for change (although excludes the social care financial challenge) and the key interventions that address this: Our financial plan brings the system close to balance Millions, Kent and Medway health system TBC Provider CCG Social care Total QIPP Spec Care ProductivityEnablers System STF STF Financial challenge challenge challenge system Comm Trans- incl. CIP Leadership funding investment challenge, challenge QIPP formation 2020/21, postintervention Assumed 100% investment of STF funding to deliver transformational change and service developments Further work required to refine this need. Outstanding gap relates to 29m funding for Ebbsfleet growth by 20/21 Also a capital implication of 75m. Source: STP October 2017 submission 17. The proposed budget identified in Point 10 has been categorised against three headings: i. Items that generate a financial return (i.e. care transformation, productivity and system / commissioning transformation) ii. iii. Enablers STP Leadership and PMO 18. The financial interventions that address the financial challenge align to the items in sub-point i above and a return on investment (ROI) has been calculated. No financial return has been assigned to items ii and iii from the above so these have been treated as a corporate overhead and the costs apportioned to the items detailed in sub-point i STP Budget Proposal.docx 5 Page 5 of 14 Overall Page 73 of 87

74 19. The following table outlines the position in terms of the return on investment. The table also outlines the source of the 2020/21 financial opportunity: Workstream 17/18 Spend 17/18 Opportunity* ROI (17/18) 17/18-20/21 Spend 20/21 Opportunity* 17/18-20/21 Opportunity** ROI (17/18-20/21) 1. Care Transformation 4,487 35, x Local Care 1,481 Hospital Care 1,879 Apportioned Enabler costs 958 Apportioned STP Leadership costs Productivity 3,710 75, x Productivity workstream 1,295 Apportioned Enabler costs 2,052 Apportioned STP Leadership costs , , , x 14, , , x Excluding impact of BAU CIP (at 2%p.a.) 3,710 34, x 14, , , x 3. Commissioning & System Transformation 2,214 28, x Commissioning & System Tr. workstream 1,305 Apportioned Enabler costs 773 Apportioned STP Leadership costs 137 8, , , x TOTAL 10, , x 41, , , x Enabler workstreams Project Management Office Comms & Engagement Accomodation Legal Fees Urgent Care Workforce Mental Health Estates Workstream Digital Contingency Income STP Leadership *17/18 Opportunity taken as 25% of 20/21 Opportunity figures 3,783 1,434 1, *Source for 20/21 Opportunity 1. PMO calculated 20/21 opportunity incl. QIPP: 190m Less QIPP (Oct 16 STP Submission): ( 50m) = 140m 20/21 Care Transformation opp Oct 16 STP 20/21 opportunity = 102m 2. PMO calculated 20/21 opportunity: 300m for Productivity 3. Oct 16 STP 20/21 System Transformation opportunity: 113 QIPP = 50m Spec Comm QIPP = 51m System Leadership = 12m **17/18-20/21 Opportunity Assumes realisation of 20/21 opportunity: 25% in 17/18; 25% in 18/19; 25% in 19/20; 100% in 20/ A one year (2017/18) ROI has been calculated using 2017/18 budgeted costs of 10.4m against the 2017/18 opportunity, calculated as 25% of the full 2020/21 opportunity of 553m (this sum is greater than the opportunity identified in the STP submission due to modelling identifying a greater potential benefit around productivity and the shift to local care than presented in the STP high-level financial plan). 21. For the purposes of this paper a four-year (2017/18 to 2020/21) ROI has been calculated using assumed budgeted costs per annum of 10.4m against the 2020/21 financial opportunity and assumes a 25% delivery of this in 17/18; 25% in 18/19; 25% in 19/20; and 100% in 20/ In summary, the above table shows the following return on investment calculations: ROI 2017/18 ROI 2017 to 2021 Care Transformation: 7.8x 13.7x Productivity: 20.2x 35.4x Productivity (excluding 2% CIP on the assumption this would be delivered in do nothing / business as usual scenario) System / commissioning transformation: 9.3x 16.3x 12.8x 22.3x Total 13.3x 23.2x STP Budget Proposal.docx 6 Page 6 of 14 Overall Page 74 of 87

75 Commercial case is the proposal commercially viable? 23. As indicated current PMO arrangements are provided through external support but an internal team is in the process of being established. As a general principle support to take forward the STP will be provided from internal resources from the partner STP organisations. However, it is also recognised that there is a need to bring in specialist expertise and there are also capacity constraints, which means it is necessary to rely on external support. 24. Where there is a requirement for external support this will be agreed through the programme board and identified through robust processes in line with the host organisation s standing financial instructions to ensure that financial transactions are carried out in accordance with the law and government policy to achieve probity. 25. As the STP is not an organisation any employment or contractual liabilities need to be held by one of the STP partner organisations. At this point, Maidstone and Tunbridge Wells NHS Trust and Kent Community Health NHS Foundation Trust have acted as host organisations but there may be a merit in spreading the liabilities across a larger number of STP partner organisations and it is suggested that the STP finance group are asked to consider this further. 26. It is proposed that the STP budget continues to be held by Maidstone and Tunbridge Wells NHS Trust. Financial case how will the resource requirement be funded? 27. Partner organisations to the STP are asked to contribute costs to cover the budget requirements outlined in this paper. 28. Three methodologies have been considered for the apportionment of costs: i. A simple split of costs split between the sixteen STP partner organisations ii. iii. A split of costs pro rata to the 2016/17 turnover of the sixteen STP partner organisations A composite methodology with 50% of costs apportioned as a simple split of costs between the sixteen STP partner organisations and 50% of costs apportioned pro rata to 2016/17 turnover 29. For the purposes of this paper 2016/17 turnover has been identified as outlined in the following table (subject to validation): STP Budget Proposal.docx 7 Page 7 of 14 Overall Page 75 of 87

76 Turnover 16/17 Organisation (Inc Spec) '000 % NHS Dartford, Gravesham and Swanley CCG 412,154 8% NHS Medway CCG 463,143 9% NHS Swale CCG 179,948 3% NHS Thanet CCG 268,588 5% NHS Canterbury and Coastal CCG 336,372 6% NHS South Kent Coast CCG 357,593 7% NHS Ashford CCG 191,406 4% NHS West Kent CCG 727,674 13% Maidstone And Tunbridge Wells NHS Trust 415,634 8% Medway NHS Foundation Trust 276,457 5% Dartford And Gravesham NHS Trust 253,113 5% Kent And Medway NHS And Social Care Partnership Trust 185,279 3% East Kent Hospitals University NHS Foundation Trust 565,676 10% Kent Community Health NHS Foundation Trust 218,203 4% Medway Council 100,000 2% Kent County Council 453,000 8% Contribution 5,404, Discussions at the STP Programme Board have outlined that: A simple split of the cost between organisations disadvantages smaller organisations A split of costs based on turnover disadvantages larger organisations 31. Based on the above, the composite methodology, as outlined in Point 24, sub-point iii, is proposed. Management case Is the proposal achievable and can it be delivered successfully? 32. As outlined in the strategic case the status quo is not an option as services are neither sustainable nor delivering the care we want for our population. Whilst challenging the STP is outlining a change programme that is achievable and is being progressed against a robust programme management discipline. 33. The critical path for the care transformation elements of the programme are in the process of being reviewed to take account of delays associated with the general election and Purdah impacting on our ability to engage. The critical path is detailed below but this remains subject to review, including considerations around how to get to consultation at an earlier juncture: STP Budget Proposal.docx 8 Page 8 of 14 Overall Page 76 of 87

77 34. The programme governance arrangements have already been summarised in this paper. The deliverables of the thirteen workstreams outlined in the governance structure were reviewed through the check and challenge sessions outlined in this paper. This process ensured that the key inputs to deliver the stated objective of the STP had been identified. The key deliverables by workstream are summarised in Attachment A risk and issues register is being maintained for the programme and monitored and managed through the PMO, Management Group and Programme Board. The current significant risk to delivering the STP objectives against the critical path outlined above have been identified as: STP Budget Proposal.docx 9 Page 9 of 14 Overall Page 77 of 87