NORTH CENTRAL LONDON ( NCL ) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday 3 rd August 2017 from 3pm - 4.20pm Seminar Room 2, Resource for London, 356 Holloway Road, London N7 6PA Present: Voting Members: Ms Sorrel Brookes (Chair) Dr Mo Abedi Dr Peter Christian Ms Bernadette Conroy Ms Kathy Elliott Mr Simon Goodwin Dr Neel Gupta Ms Catherine Herman Ms Helen Pettersen Dr Jo Sauvage Dr Barry Subel Governing Body Lay Member, Islington CCG Governing Body Chair, Enfield CCG Governing Body Chair, Haringey CCG Governing Body Lay Member, Barnet CCG Governing Body Lay Member, Camden CCG NCL Chief Finance Officer Governing Body Chair Elect, Camden CCG Governing Body Vice Chair and Lay Member, Haringey CCG NCL Accountable Officer Governing Body Chair, Islington CCG Clinical Vice Chair, Barnet CCG Non-Voting Members: Cllr Janet Burgess Councillor, Islington Council Ms Sharon Grant Healthwatch Chair, Haringey Cllr Val Duschinsky Councillor, Barnet Council Dr Jeanette De Gruchy Director of Public Health, Haringey Council Cllr Richard Olszewski Councillor, Camden Council In Attendance: Mr Paul Sinden Mr Andrew Spicer Apologies: Cllr Jason Arthur Cllr Alev Cazimoglu Ms Deborah Fowler Dr Debbie Frost Cllr Hugh Rayner Ms Karen Trew Minutes Mr David Triggs NCL Director of Performance and Acute Commissioning NCL Head of Governance and Risk Councillor, Haringey Council Councillor, Enfield London Borough Council Chair, Healthwatch Enfield Governing Body Chair, Barnet CCG Councillor, Barnet Council Governing Body Vice Chair and Lay Member, Enfield CCG Board Secretary, Enfield CCG
1. Introduction 1.1 Welcome 1.1.1 The Chair welcomed everyone to the meeting and invited introductions around the table. It was noted that this was the second meeting of the NCL Joint Commissioning Committee ( JCC ) under the new commissioning arrangements for NCL CCGs. 1.2 Declarations of Interest 1.2.1 These were noted as recorded in the papers subject to corrections to the interests of Simon Goodwin which were recorded incorrectly. Simon Goodwin confirmed the following interests: Chief Financial Officer for the 5 CCGs in North Central London (Barnet, Enfield, Haringey, Islington and Camden); Wife is a senior manager at East London NHS Foundation Trust. 1.3 Declarations of Gifts and Hospitality 1.3.1 There were no declarations of gifts or hospitality offered or received. 1.4 Minutes of the Meeting on 6 th July 2017 1.4.1 The minutes were approved as an accurate record. 1.5 Action Log 1.5.1 The following updates were given: Action 1: Committee Terms of Reference: These were on the agenda for this meeting. Action completed; Action 2: Acute Commissioning Report (Whittington Health): Paul Sinden explained that the report included both acute and community contract baselines for Whittington Health. Future papers would disaggregate information between acute commissioning and community services for the Trust; Action 3: Acute Commissioning Report (Royal Free): The Acute Commissioning report in the papers covered the issue of data quality for the August 2017 meeting. Action completed; Action 4: Transforming Care Programme: It was noted that an update on costings would be presented to the Committee in October 2017; Action 5: Transforming Care Programme: A risk relating to quality assurance of packages of care established in the community had been added to the risk register, and shared with CCGs for inclusion into local registers. Action completed; Action 6: Transforming Care Programme: Updates on quality assurance process included in the Committee papers for August 2017. Action completed; Action 7: Committee Risk Register: The register had been updated for the operational risks identified at the July 2017 Committee. Further discussion would be undertaken as part of the seminar to be held in September 2017 with a focus on strategic risks. 1.6 Questions from the Public 1.6.1 There were no questions from the public. It was noted that the next formal Committee would be held on 5 October 2017 commencing at 3pm. 2 Governance 2.1 Terms of Reference Update
2.1.1 The Committee received and noted the updated terms of reference. Barnet CCG had approved the term of reference via Chair s action. Each of the other four CCG Governing Bodies had approved the terms of reference. It was noted that the main changes to the terms of reference included: Three independent clinicians to be appointed to the Committee with at least one being a nurse and one being a secondary care clinician; Recruitment of independent clinical members permitted using existing CCG Governing Body members; The nurse representative could be appointed from primary care as well as secondary care background; Two Healthwatch representatives rather than one; Clarity on voting and non-voting members; Part two meetings to be kept to a minimum and minutes to be shared at the next Part One meeting. 2.1.2 It was noted that recruitment of the independent chair and independent clinical members of the Committee was underway and expressions of interest had been received for all posts. 2.1.3 The Committee discussed and noted the report. 3 Activity and Performance 3.1 Acute Commissioning Report 3.1.1 The Committee considered a report that set out an overview of provider contracts for which management had been delegated to the Joint Commissioning Committee. The report incorporated acute hospital contracts and the Integrated Urgent Care service (NHS 111 and GP out-of-hours) provided by London Central and West (LCW) Unscheduled Care Collaborative. 3.1.2 The intention was to also use this report in the future within CCG Governing Bodies and supporting Committee structures to prevent duplication of reporting. It was noted that the report would continue to evolve. The Director of Performance and Acute Commissioning highlighted key areas of the report by exception. 3.1.3 Cancer 62 day standard: The North Central London (NCL) trajectory had recently been refreshed, with the expectation that the standard would be achieved by September 2017. There was an assumption within this that UCLH would not recover its position until March 2018. The NHS Constitution standard is that 93% receive treatment within 62-days of GP referral. The recovery trajectory for NCL was achieved in April and May 2017, but un-validated performance in June was at 73% against a trajectory of 76% (validation of pathways usually increases performance, so final June position expected to be close to trajectory). For June 2017 the Committee noted that: UCLH achieved its improvement trajectory; The main lag in performance accrued from Royal National Orthopaedic Hospital, commissioners are working with the Trust on its remedial action plan to recover performance; Analysis of waiting list trends indicates a risk of a backlog of work at Whittington Health. 3.1.4 Recovery of the 62-day target was centred on a five-point plan that focused on: Reducing median waits from GP referral to first outpatient appointments to seven-days (the national standard is fourteen days); Implementing optimal pathways for lung and cancer with the focus on these pathways as they have historically had the most 62-day breaches, and straight-to-test for lower gastro-intestinal patients on the two-week pathway from GP referral to provide earlier diagnostic analysis; Inter-provider transfers being within 38 days of the 62-day pathway to allow recipient Trusts time to complete treatment;
Waiting list management (daily) to stop avoidable breaches; Root cause analysis of all 62-day breaches plus harm reviews for any waits in excess of 100 days. 3.1.5 A&E: Performance across the sector was variable, with no NCL providers achieving their improvement trajectories for quarter one in 2017/18 with the exception of Whittington Health. A degree of improvement was apparent although clearly further was required to meet trajectories and retain the 95% standard. 3.1.6 Emergency Departments with the most fragile performance were North Middlesex University Hospital (NMUH) and Barnet Hospital with both units yet to de-escalate from winter bed capacity. Both were the focus of escalation meetings with NHS England and NHS Improvement. The Committee requested that performance data for the Royal Free and Barnet sites separately rather than be amalgamated for the Trust as a whole. It was noted that CCG teams had walked the emergency care pathways at NMUH to experience the pressure the unit operated under, understand the patient experience, and identify opportunities for pathway improvements. Details were presented around the work to sustain patient flow at NMUH that included: Alternatives to A&E including streaming into urgent care by emergency nurse practitioners and communications to ensure expended access primary care hubs were used effectively; Efficient patient flows within the hospitals including use of ambulatory care; Ensuring community capacity to reduce the number of people in hospital beds who could be discharged into community services or return home (delayed transfers of care and medically optimised patients). 3.1.7 It was noted that each A&E Delivery Board in North Central London had to submit plans for winter 2017/18 to NHS England and NHS Improvement by the end of September 2017, with plans demonstrating capacity in hospitals, community services, social care, primary care and mental health to cope with additional emergency patient flows over the winter. It was noted that UCLH had also experienced issues in maintaining the A&E standards and had been outside targets since April 2017. 3.1.8 Referral to Treatment ( RTT ): Although NCL as a whole was currently achieving the RTT standard, there was a risk that the position may start to deteriorate due to the focus on other areas such as Cancer and A&E. Pressure on delivering this waiting time standard was indicated by the growth in the number of people waiting for treatment. The standard that 92% of people waiting for treatment had been on a waiting list for less than 18 weeks was currently met on an aggregate level in North Central London (92.8%), and this compares favourably to performance across London (88.7%). During discussion of the report members requested further information be provided, including waiting list profiles to enable better trend analysis. 3.1.9 Patient Experience. Friends and Family Test ( FFT ) received a low positive response rate at North Middlesex University Hospital for outpatient appointments, maternity and A&E attendances relative to other providers in North Central London and across London. 3.1.10 Diagnostics. Performance against the six-week waiting time standard was on an improving trend for North Central London providers. The standard that 99% of people receive their test within 6 weeks is currently met on an aggregate level in North Central London (92.2%), and this compared favourably to performance across London (98%). 3.1.11 London Ambulance Service. The disparity in performance across NCL boroughs for the ambulance eight-minute waiting time standard from call to arrival for emergency calls was under investigation, with improvement plans in place for Barnet, Enfield and Haringey. NCL performance was 69.5% against the 75% standard in May 2017 (68.9% in April), with performance varying from 82.4% in Camden to less than 65% in Barnet, Enfield and Haringey. 3.1.12 Integrated Urgent Care. The report on investigations carried out into allegations made in The Sun would be received by the Committee in October 2017. The allegations resulted in declaration of a serious incident, and the provider was fully co-operating with the investigations. The NCL
Clinical Responsible Officer undertook an immediate assessment to ensure the service was safe to continue, and from this commissioners and NHS England agreed that there was no evidence identified to suggest that the service was unsafe or that any patient harm had occurred. 3.1.13 Contracts and finance. The Committee received financial information restricted to contracts that had been delegated to the Joint Commissioning Committee (JCC). Contract performance in 2017/18 was framed within the two-year contracts for 2017/18 and 2018/19 as signed in December 2016. 3.1.14 Provider data quality. The Committee noted that data quality in provider reports for May 2017 had improved compared to the April 2017 reports. The claims and challenges process indicated that most concern over data quality accrued from Royal Free London. 3.1.15 Over performance against contract remains a key risk for all CCGs in 2017/18. At month 3 NCL CCGs have reported overall year-to-date acute over performance of 447k and a forecast outturn over performance of 3.1m. 3.1.16 The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a 5.7m reduction in forecast outturn. The deterioration in forecast outturn compared to the year-to-date position accrues in part from risk-assessed local delivery of STP and local Quality Innovation Productivity and Prevention ( QIPP ) interventions. Progress on QIPP plans were reported at each CCG Governing Body. 3.1.17 The underlying year-end position on acute contracts on a full payment-by-results tariff (after removing the impact of marginal rates applied in-year) would be over performance of 8.9m at month three. 3.1.18 The report provided an overview of contracts by providers identifying risks and mitigating actions to address those risks. 3.1.19 The following key risks were noted: The underlying contract run-rates for 2017/18 being in excess of 2016/17 with the exception of Whittington Health at month three; The use of marginal rates to counter over performance in 2017/18 ( 5.7m assumed for the year-end at month three); Significant reported over performance at Royal Free Hospital, particularly in diagnostic imaging, electives and outpatients; Disproportionate increases in price compared to activity trends across NCL providers for electives, outpatient first attendances and outpatient follow-ups; The impact of A&E up-coding at North Middlesex University Hospital and Whittington Health; The dependence on delivery of Sustainability and Transformation Plan (STP) interventions to bring contract performance back to planned levels. At month three local risk assessments indicated 7m slippage on impact; The cost pressure to CCGs accruing from the introduction of the new tariff, with costs being 11m over the funding adjustment received by the five CCGs. 3.1.20 Mitigations were noted as follows: Existing marginal rate arrangements to be continued into 2018/19, as included within signed contracts and 2018/19 System Intentions. At present, the forecast outturn assumes a saving of 5.7m due to marginal rate application; Additional capacity from CCG and North East London Commissioning Support Unit (NELCSU) teams identified to support delivery of STP interventions; Deep-dives initiated at Royal Free to understand the over performance in diagnostic imaging, which was believed to have been caused by a counting and coding error. This was being addressed through contractual routes and challenges had been issued to understand the growth in electives and outpatients;
Investigations and contract challenges (in line with national contract guidelines) and the process agreed for 2017/18; Investigation into the impact of both tariff changes and IR (Identification Rules) changes between CCGs and Specialist Commissioning to continue throughout the year, with recommendations made to CCGs to challenge regulatory bodies where appropriate. 3.1.21 Actions: To develop the performance report to enable JCC to see trends going forward; To separate out information for the Royal Free and Barnet Hospital sites for A&E performance; To receive an update on plans for winter 2017/18. 3.1.22 The Committee discussed and noted the report. 3.2 Learning Disabilities Transforming Care Cohort 3.2.1 The Committee considered an update report on the Transforming Care Programme which aimed to reduce the number of hospital beds commissioned for patients with a learning disability and/or autism and transfer their care into the community by March 2019. The programme had been established in response to the Winterbourne View scandal. 3.2.2 The report addressed a request for further information by the Committee on the quality assurance process for transferring care from inpatient settings into community packages in July 2017. 3.2.3 Legal challenges to the transfer of packages of care into the community had been received from families of people in placements at Harperbury Specialist Residential Services in Hertfordshire. Changing our Lives, an independent rights based learning disability rights group, had been commissioned to undertake detailed life planning for each resident, and Hertfordshire Council were providing an overview of social work services and co-ordination of legal services (not legal representation) on behalf of all patients. 3.2.4 Service developments to support the Transforming Care Programme with these services including: Multi-Agency Hub, incorporating a care team to coordinate discharge and pilot multiagency case conferences for long stay in-patients. Starts September 2017; Positive Behaviour Support (PBS) School of Excellence, to develop best practice PBS across NCL, including providers, support workers, and families. Service specification in development; Accommodation Project, to source property for patients requiring bespoke solutions. Starts October 2017. 3.2.5 The Committee would receive a report on the financial impact of the Programme in October 2017 following a more detailed assessment of the cost of community packages of care for both health and social care. 3.2.6 It was noted that financial and qualitative risks for the Programme had been included in the JCC risk register. 3.2.7 During discussions there was reference to the need to provide more information on the Transforming Care Programme and link this to local CCG web sites. It was also agreed that legal costs be carefully monitored and an update be provided at the October meeting. 3.2.8 Actions: The need for more information to be provided and to link to local CCG web sites To provide an update on any legal costs incurred at the October 2017 meeting. 3.2.9 The Committee discussed and noted the report.
4 Commissioning 4.1 System Intentions 2018/19 4.1.1 The Committee considered a paper setting out an initial draft of system intentions for 2018/19. The report highlighted a shift from commissioning to system intentions in recognition of Sustainability and Transformation Plan (STP) and new NCL CCG commissioning arrangements. 4.1.2 The intentions were underpinned by a set of principles for the system to work together, building on those used to agree contracts for 2017/18 and 2018/19. 4.1.3 The System Intentions focused on: Delivery of Sustainability and Transformation Plan (STP) priorities; Local priorities for CCGs agreed with local stakeholders; The context of financial challenges in the health and care system and the development of a financial strategy for NCL; A focus on alignment of CCG intentions to present an aggregate and coherent picture to providers, but with room for individual CCG intentions outside of the STP; Greater alignment with specialist commissioning; The need to continue work on system incentives and contract form to better align system incentives to support delivery of the STP; Contract requirement for 2018/19 and in particular the need to set contract baselines for 2018/19; Joint commissioning with local authorities and extending this beyond social care to cover housing, employment and prevention; National planning priorities including the refresh of the Five Year Forward View. Any formal guidance for 2018/19 had yet to be published by NHS England / NHS Improvement. 4.1.4 The Committee were asked to consider planning assumptions for 2018/19 as these would be used to derive contact baselines for the next year. The baseline for 2018/19 would be based on the run-rate from contracts in 2017/18. 4.1.5 It was noted that System Intentions signalled the trialling of contract forms in 2018/19 as an alternative to payment-by-results (cost and volume contracts) for hospital providers to better align system incentives. Work was underway with providers to achieve this, with potential to switch to new contract models in 2019/20 if agreed by commissioners and providers. 4.1.6 The Committee supported the work on contract form as a signal for new ways of working between commissioners and providers as the best way to support delivery of new service models in the STP and to resolve the overall financial deficit in NCL. 4.1.7 The Committee requested that a plain English version of System Intentions be developed for use with broader stakeholders. 4.1.8 Actions: To develop locally focused plain English version of System Intentions. To take the System Intentions to each CCG Governing Body in September 2017. 4.1.9 The Committee discussed and noted the report. 4.2 Alignment Opportunities for CCG and Specialist Commissioning 4.2.1 It was noted that many providers in North Central London had contracts with both CCGs and Specialist Commissioning. The Committee reviewed a paper that proposed ways for the two commissioning teams to build on existing links and effectively manage provider contracts through:
Joint contract management frameworks and meetings with providers; Taking on lead commissioning arrangements where either CCGs or Specialist Commissioning held the vast majority of contract value with a provider; Co-commissioning of care pathways that straddle services commissioned by CCGs and Specialist Commissioning to improve patient pathways and experience; Paul Sinden indicated that the acute commissioning report would include an update on the impact of changes to allocation rules between CCGs and Specialist Commissioning contract performance. 4.2.2 The Committee discussed and noted the report. 5. Risk 5.1 NCL Joint Commissioning Committee Risk Register 5.1.1 The Committee received an update to the risk register which aimed to capture the main risks for the JCC. The risk register had been updated for the additional operational items discussed by the Committee at its meeting in July 2017. The register would be further update to reflect strategic risks as well as operational risks. 5.1.2 The new risks added to the register included: Effective communication of the remit of the Joint Commissioning Committee to stakeholders; Ensuring member attendance at the Committee; Ensuring relationships with providers were sufficiently robust to enable delivery of contracts for 2017/18 and 2018/19; Mobilisation of STP and CCG QIPP plan interventions to ensure contracts are delivered within budgets; Management of acute contracts to avoid over performance and deliver 2017/18 contracts within baselines; Ensuring the needs of individuals are met as packages of care are transferred into the community for the Transforming Care cohort within Learning Disabilities. 5.1.3 It was recommended that risks with a pre-mitigation score of 16 or more be placed on CCG risk registers. From the August register this included: Delivery of waiting time standards for cancer 62-days and A&E 4-hour wait; Managing acute contracts within budgets; Mobilisation of STP and QIPP plans. 5.1.4 Action: To incorporate strategic risks into the risk register for the Committee. 5.1.5 The Committee discussed and noted the report. 6. Public Questions 6.1 There were no questions asked. 7. Any Other Business 7.1 Committee Forward Plan 2017/18
7.1.1 The JCC noted that the forward planner had been changed to reflect the revised dates for Committee meetings and seminars adjusted to avoid clashes with CCG Governing Body meetings. 7.1.2 It was noted that items for the October meeting would include: Standing items for acute commissioning and risks; An update on Transforming Care Programme financial forecasts; System intentions for 2018/19 sent to providers on 30 September 2017; Procedures of limited clinical effectiveness (PoLCE) NCL CCGs adopting Enfield CCG approach for adherence to evidence-based medicine subject to consultation; Receipt of investigations into LCW Integrated Urgent Care service. 7.1.3 It was noted that subjects for Seminar scheduled for 7 September 2017 included: Review of acute commissioning paper; Work on contract form and system incentives; Preparation of system intentions for 2018/19; Risk register development of strategic risks. 7.1.3 The Committee discussed and noted the 2017/18 Forward Planner. 7.2 Any Other Business 7.2.1 The Accountable Officer asked the Committee to consider a request received from the Local Medical Committee ( LMC ) to be a member of the JCC. 7.2.2 The Committee considered that the JCC was meeting held in public and there was no reason that the LMC should not attend meetings. However, the main remit for the JCC was acute commissioning/ secondary care and there was no reason for the LMC to be added to the committee s membership. LMC was a member of the Primary Care Co-commissioning Committee and this was considered appropriate. 7.2.3 The Committee discussed the request. The Committee agreed that membership of the JCC not be expanded to include Local Medical Committee representation. 8. Date of Next and Future Meetings 8.1 The next Committee meetings are: 5 th October 2017 from 3pm to 5pm; 7 th December 2017 from 3pm to 5pm; 1 st February 2018 from 3pm to 5pm. 8.2 Meeting Close 8.2 The meeting closed at 4.20pm. These minutes are agreed to be a correct record of the Part 1 meeting of North Central London Joint Commissioning Committee held on Thursday 3 rd August 2017 Signed.. Date