Agenda Item: LW2015/115 FOI Exempt: N Leeds West CCG Governing Body Meeting Date of meeting: 4 vember 2015 Title: Delegated Commissioning of Primary Medical Services Lead Governing Body Member: Dr Simon Stockill, Medical Director Report Author: Kirsty Turner, Associate Director of Primary Care / Laura Parsons, Head of Business & Corporate Services / Sam Mason, Finance Manager Reviewed by SMT: 28 October 2015 Reviewed by Committee: N/A Checked by Finance: Y Category of Paper Decision and Approval Information Discussion Tick as appropriate () Approved by Lead Governing Body member (Y/N): Y Strategic Objectives that this report relates to Tick as appropriate () 1. To tackle the biggest health challenges in West Leeds, reducing health inequalities 2. To transform care and drive continuous improvement in quality and safety 3. To use resources effectively 4. To work with members to meet their obligations as clinical commissioners at practice level and to have the best developed workforce we possibly can Joint Health & Wellbeing Strategy Outcomes that this report relates to Tick as appropriate () 1. People will live longer and have healthier lives 2. People will live full, active and independent lives 3. People will enjoy the best possible quality of life 4. People are involved in decisions made about them 5. People will live in healthy and sustainable communities Assurance Framework - to which risks on the GBAF does this report relate? Ref 7: There is a risk of failure to achieve financial stability and sustainability. Ref 5a: There is a risk that Leeds West CCG member practices do not engage adequately as clinical commissioners Ref 5b: There is a risk that Leeds West CCG member practices do not engage adequately as providers of primary medical services. 1
EXECUTIVE SUMMARY: There is a further opportunity for CCGs to participate in the co- of primary medical services, with NHS England inviting a further round of applications. The scope of primary care co- relates to general practice services only and there are 3 levels to apply for: Greater decision making Joint arrangements Full delegated arrangements A suite of supporting papers have been produced to support NHS Leeds West CCG s application for delegated of primary medical services which includes: The views of our member practices Governance documentation - proposed Terms of Reference for the Primary Care Commissioning Committee, Constitutional amendments and updates to the Declarations of Interest Policy Financial Due Diligence and resourcing recommendations NEXT STEPS: Applications for delegated need to be received at NHS England by Midday 6 vember 2015, ready for implementation on 1 April 2016. Following submission, NHS England have indicated that regional panels will be established to review the proposals and make recommendations to a national panel on which proposals to take forward with an aim to complete the process by the end of 2015. Following submission we will continue to work with NHS England, our members, our staff and our colleagues and partners across the City to understand how we can work collaboratively to implement co- effectively. RECOMMENDATION: The Governing Body is asked to: (a) NOTE the views of member practices (Appendix 2); (b) NOTE and ACCEPT the financial implications of delegated (Appendix 3); (c) APPROVE the proposed Terms of Reference for the Primary Care Commissioning Committee (Appendix 4); and (d) APPROVE the recommendation to apply for delegated of primary medical services. 2
DELEGATED COMMISSIONING OF PRIMARY MEDICAL SERVICES 1. SUMMARY 1.1 Co- is one of the initiatives that was highlighted in the NHS Five Year Forward View which intends to support organisations to influence the way the whole of NHS funding is being invested for local populations and support effective integrated care outside hospital. Therefore leading to a range of benefits for the public and patients, including: Improved access to primary care and wider out-of-hospitals services, with more services available closer to home; High quality out-of-hospitals care; Improved health outcomes, equity of access, reduced inequalities; and A better patient experience through more joined up services. 1.2 The scope of co- is general practice services only (excludes primary care pharmacy, dentistry and ophthalmic services); however for delegated arrangements this includes contractual GP performance and budget. Co- excludes all functions relating to individual GP performance (medical performers lists for GPs, appraisal and revalidation) and complaints. 1.3 Nationally there are 63 CCGs assuming delegated responsibility for the of general practice services and 86 CCGs undertaking joint arrangements with NHS England. 1.4 Ian Dodge, National Director for Commissioning Strategy at NHS England and Dr Amanda Doyle, Chief Clinical Office at NHS Blackpool CCG (on behalf of the Primary Care Co- programme oversight group) have recently written to CCGs to encourage to apply for full delegation (see Appendix 1). They state that the early benefits of delegated are: Increased local appetite and energy to develop primary care services and new models of care. Enabled the development of a clearer, more joined up vision for primary care (aligned to CCGs wider system priorities). Increased clinical leadership and public primary care, enabling more local decision making. Improved CCGs relationships with a wider range of local stakeholders, including member practices as more conversation are now happening locally about primary care development and practice sustainability. 1.5 In Leeds, members and the Governing Body previously approved a proposal whereby the 3 CCGs opted to work jointly with NHS England on the of primary medical services, however due to some changes in the process post submission this resulted in the 3 CCGs actually working at level 1 which is greater decision making. 1.6 The original application signalled a direction of travel for the Leeds CCGs to move towards full delegation of (level 3) on the basis that proceeding at 3
level 2 would provide a stepped change so that the CCGs could understand the risks associated with full delegation. 2.0 PRIMARY CARE CO-COMMISSIONING 2.1 We have already developed our Primary Care Improvement Strategy for Leeds West and have made significant progress in delivering this. Co- will further help us to achieve our vision for primary care which has continued to progress throughout this year in line with the evolving vision for the new models of care through multi-speciality community providers. 2.2 We will be able to do this by having more control of the wider NHS budget to facilitate a shift in investment from acute to primary and community services. 2.3 The Leeds West CCG website states that The CCG is very different from previous NHS organisations. For the first time, healthcare services will be commissioned by organisations that are led by locally based doctors and nurses, supported by experienced managers. This means we can have a real, detailed understanding of the health and social care issues there are in our neighbourhoods, and a genuine opportunity to shape health services at a much more local level as well as across the city of Leeds. This statement also applies to the provision of primary care services whereby as CCGs working with our member practices we understand general practice in our area and committed to improving quality and range of services within our practices. 2.4 Within the current system there is confusion as to who is responsible for what aspects of or primary care activity which is confusing for members, staff, patients and the public. Being the accountable organisation with delegated responsibility will ensure that this confusion and any risk associated are mitigated. 2.5 We have already commenced from general practice through our Enhanced Access and Care Home schemes, both of which test out new arrangements for general practice services. 2.6 On a practical basis, the recent award of the Prime Ministers Challenge Fund has led to some detailed conversations around the arrangements for the Primary Care Network; whilst this is a positive step in the maturity of our member practices it has caused a number of additional costs namely associated with legal and accountant costs. If the CCG had delegated arrangements we would have been able to receive the funds on behalf of the members. 2.7 The co- functions were summarised in the vember 2014 guidance as being: Primary care function General practice Greater involvement discussions but no Joint team Delegated 4
Primary care function Pharmacy, eye health and dental Design and implementation of local incentive schemes General practice budget Complaints Contractual GP practice performance Medical performers list, appraisal revalidation Greater involvement discussions but no Opportunity for performance discussions Joint discussion but no Subject to joint agreement with the area team teams teams teams Delegated discussions but no 3.0 STATUTORY/LEGAL/REGULATORY/CONTRACTUAL ISSUES 3.1 The CCG has tested out its governance procedures over the past year in the approval of a number of business cases which invest in general practice. In all cases, the GP members have been removed from the decision making process. In relation to the enhanced primary care scheme, the actual decision was delegated to the Assurance Committee to manage conflicts of interest appropriately. Since then, the quorum has been revised to ensure that the Governing Body can make decisions when all of the GP members have a conflict of interest. 3.2 A new committee of the Governing Body would need to be established to make decisions on primary care. The committee must have a lay and executive member majority and standing invites must be made to Healthwatch and the Health and Wellbeing Board to appoint representatives to attend meetings (in a non-voting capacity). The Chair and Vice Chair must be Lay Members and meetings must be held in public. The proposed Terms of Reference are attached at Appendix 4 for approval. 3.3 The CCG s Constitution would also need to be amended to include reference to the Primary Care Commissioning Committee and to include the Committee s functions in the overarching scheme of delegation. The Constitution amendments are the subject of a separate item on today s agenda (LW2015/116). 3.4 Guidance was issued in December 2014 on managing Conflicts of Interest based on co- arrangements. The CCG s Declarations of Interest Policy was revised to take account of the guidance and further amendments are proposed to 5
strengthen this policy (see agenda item LW2015/114). We are currently receiving details of conflicts of interest from members in light of this guidance and will be ensuring this is placed on our website in the interest of transparency. 3.5 The Internal Auditors have reviewed our preparations for applying for delegated arrangements, including the required documentation such as Constitution amendments and terms of reference, and have provided a rating of significant assurance. 4.0 FINANCIAL IMPLICATIONS AND RISK 4.1 A full financial review has taken place which is attached at Appendix 3. Whilst some financial risks are associated with taking on full delegated responsibility the overall recommendation is to continue to proceed to move to full delegation. 4.2 The following risks have been highlighted: Risk Mitigation RAG Capacity There is a risk that there is not sufficient capacity within teams to support the agenda. Continue to work with NHS England to look at the Memorandum of Understanding to understand roles and responsibilities. Furthermore continue to work with Citywide colleagues to look for opportunities to develop joint functions where possible. We are also exploring a Citywide developmental group which would bring together clinical and managerial leads to learn and share from each other and also look to explore initiatives that would benefits from a Citywide approach i.e. reviewing QOF. Finance Some specific financial risks have been identified (see Appendix 3) Relationships Being responsible for the of primary care will change the relationship of a members led organisation. Internally, teams to review their capacity to identify how they may need to adjust to meet the changing requirements of co-. Financial review process undertaken to identify all known risks (see Appendix 3) The role of the organisation has already evolved and the primary care team has had to have some difficult conversation already due to our increased input. The strength of the relationship with our members means that whilst difficult conversations can take place this can be done in a positive way. To support the changing role the primary care team has already 6
identified a separation of roles between assurance/contracting and a more developmental/supportive role. Governance We will need to review our governance arrangements to take on the additional primary care responsibilities including establishing a new committee resulting in additional responsibilities for lay members. Leeds West CCG has already developed robust arrangements for managing conflicts of interest during decision making processes. 5.0 COMMUNICATIONS AND INVOLVEMENT 5.1 The outcome of our application should be known by the end of 2015. During this time we will need to continue to work with our members, staff and other stakeholders to communicate our intentions. 5.2 We held an engagement event with our GP member practices patient reference groups (PRG) in March 2015 to help us develop our primary care improvement strategy. As part of this event we explained about primary care co-. We gave a commitment to share plans with our patients and public once these are more detailed and developed. It is also imperative that we engage with our patients so that we can provide assurance around our approach to managing conflicts of interest. Any changes to commissioned services would obviously continue to be engaged and consulted upon at the appropriate time. 6.0 RECOMMENDATION The Governing Body is asked to: (a) NOTE the views of member practices (Appendix 2); (b) NOTE and ACCEPT the financial implications of delegated (Appendix 3); (c) APPROVE the proposed Terms of Reference for the Primary Care Commissioning Committee (Appendix 4); and (d) APPROVE the recommendation to apply for delegated of primary medical services. 7