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Islington Clinical Commissioning Group Governing Body Business Meeting Wednesday 11 September 2019 9.30-11.00 Resource for London, Seminar 3, First Floor, 354 Holloway Road, London N7 6PA.

AGENDA - Part 1

Item Title Lead Action Papers Page No

Time

1 INTRODUCTION 1.1 Welcome and Apologies Chair To note Oral

9.30 to

9:40

1.2 Declarations of Interest Register Chair To note 1.2 4

1.3 Declarations on Interest relating to the items on the Agenda

To note Oral

1.4 Declarations of Gifts and Hospitality

Chair To note Oral

1.5 Draft minutes of previous Governing Body meeting on 12 June 2019

Chair For approval

1.5 13

1.6 Action Log Chair For approval

1.6 20

1.7 Questions from the public

2 OVERVIEW REPORTS

2.1 Accountable Officer’s Report

Helen Pettersen

(Accountable Officer)

To note 2.1 22 9.40 to

9:50

3. CORPORATE BUSINESS & BUSINESS CASES

3.1 NCL response to the NHS Long Term

Plan: developing our collective plans

Will Huxter (NCL Director of Strategy)

To note / For

discussion

3.1 27 9:50 to

10:00

3.2

Islington Walk in Centre

Clare Henderson (Director of

Commissioning

and Integration)

For approval

3.2 62 10:00 to

10:10

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4 FINANCE AND PERFORMANCE

4.1 Finance Report Simon Goodwin (Chief Finance

Officer)

For discussion

4.1 81 10:10 to

10.20

4.2

Performance Report

Elizabeth Ogunoye

(Director of Acute

Commissioning & Performance)

For discussion

4.2 90 10.20

to 10:30

5 GOVERNANCE

5.1

Board Assurance Framework

Alex Smith (Director of

Planning and Delivery)

For discussion

5.1 99 10.30 to

10.40

5.2 NCL Primary Care Committee in Common Terms of Reference

Andrew Spicer (NCL Head of Governance

and Risk)

For approval

5.2 111 10.40 to

10.50

5.3 Patient and Public Participation Committee (PPP) Terms of Reference

Katie Coleman, (Chair of

Patient and Public

Participation Committee)

For approval

5.3 126 10.50 to

11.00

6 ITEMS FOR INFORMATION AND ASSURANCE

6.1 Minutes of the Quality and Performance Committee in Common Meeting 6.1.1 – Minutes of 23 April 2019 available here 6.1.2 - Minutes of 25 June 2019 available here

Lucy de Groot (Chair of Quality &

Performance Committee in

Common)

To note

11.00

6.2 Minutes of the Patient and Public Participation Committee (PPP) Meeting on 2 May 2019 available here

Katie Coleman

(Chair of

Patient &

Public

Participation

Committee)

To note

6.3 Minutes of the Strategy and Finance Committee in Common 6.3.1 – Meeting of 1 May 2019 available here 6.3.2 - Meeting of 27 June 2019 available here 6.3.3 - Meeting of 29 July 2019 Available here

Sorrel Brookes, (Chair of

Strategy & Finance

Committee in Common)

To note

6.4 Minutes of the NCL Joint Commissioning Committee Meeting on 6 June 2019 available here

Karen Trew, (Chair of NCL

Joint

To note

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Commissioning Committee)

6.5 Minutes of the NCL Primary Care Commissioning Committee 6.5.1 - Meeting of 18 April 2019 – available here 6.5.2 - Meeting of 20 June 2019 – available here

Catherine Herman,

(Chair of NCL Primary Care

Commissioning Committee)

To note

6.6

Minutes of the NCL Audit Committee in Common meeting of 27 March 2019 available here

Adam Sharples (Chair of NCL

Audit Committee in

Common)

To note

7 ANY OTHER BUSINESS

8 Date of Next Meeting: Wednesday 11 December 2019

Part 2 meetings

To resolve that as publicity on items contained in Part 2 of the agenda would be prejudicial to public interest by reason of their confidential nature, representatives of the press and members of the public should be excluded from the remainder of the meeting. Section 1 (2) Public Bodies (Admission to meetings) Act 1960.

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Islington Clinical Commissioning Group Governing Body Meeting 11 September 2019

Report Title Declaration of Interest Register - Islington CCG Governing Body

Agenda Item: 1.2

Governing Body

Sponsor

The Chair Tel/Email Josephine.sauvageccg@nhs.net

Lead Director /

Manager

Tony Hoolaghan - Chief Operating Officer

Tel/Email t.hoolaghan@nhs.net

Report Author

Vivienne Ahmad, Board Secretary

Tel/Email v.ahmad@nhs.net

Name of Authorising Finance Lead

Not applicable Summary of

Financial

Implications

Name of Authorising Finance Lead

Report Summary

Governing Body Members and attendees are asked to review the agenda and consider whether any of the topics might present a conflict of interest, whether those interests are already included within the Register of Interest, or need to be considered for the first time due to the specific subject matter of the agenda item. A conflict of interest would arise if decisions or recommendations made by the Governing Body or its Committees could be perceived to advantage the individual holding the interest, their family, or their workplace or business interests. Such advantage might be financial or in another form, such as the ability to exert undue influence. Any such interests should be declared either before or during the meeting so that they can be managed appropriately. Effective handling of conflicts of interest is crucial to give confidence to patients, tax payers, healthcare providers and Parliament that CCG commissioning decisions are robust, fair and transparent and offer value for money. If attendees are unsure of whether or not individual interests represent a conflict, they should be declared anyway. The declaration document has been updated to include reference to PCNs and we have commenced the annual refresh of declarations for all key parties.

Recommendation To NOTE the Declaration of Register and invite members to inspect their entry

and advise the meeting / Board Secretary of any changes.

Identified Risks

and Risk

Management

Actions

The risk of failing to declare an interest may affect the validity of a decision / discussion made at this meeting and could potentially result in reputational and financial costs against the CCG.

Conflicts of Interest

The purpose of the Register is to list interests, perceived and actual, of members that may relate to the meeting.

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Resource

Implications

Not Applicable

Engagement

Not Applicable

Equality Impact

Analysis

Not Applicable

Report History and

Key Decisions

The Declaration of Interests Register is a standing item presented to every

Governing Body Meeting.

Next Steps The Declaration of Interests Register is presented to every Governing Body Meeting and regularly monitored.

Appendices

The Declaration of Interest Register.

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NHS Islington CCG Governing Body Declaration of Interests Register 2019/20 - as at 31 August 2019

Fin

an

cia

l Inte

res

t

No

n-F

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

t

No

n-F

ina

nc

ial

Pe

rso

na

l Inte

res

t

from

to

da

te d

ec

lare

d

up

da

te

Actions taken to mitigate risk

Helen Pettersen Accountable Officer and STP Convener,

NCL

Member of all five CCG Governing Bodies

Member of all five CCG Finance

Committees

Attendee at CCG Audit Committees as

required and NCL Audit Committee in

Common

Attendee at NCL Joint Commissioning

Committee

Attendee NCL Primary Care Co

Commissioning in Common

Attendee at other committee meetings in

the five CCGs as and when relevant

Royal Borough of Kensington and Chelsea

Local Authority

no no Yes yes Husband is Programme Manager

for Partners in Practice, a social

work training programme.

15/05/2018 current 17/10/2019 20/08/2019

Tony Hoolaghan Chief Operating Officer for Haringey and

Islington CCGs

Non-Voting Member of the Governing

Body for Haringey CCG & Islington CCG

Haringey & Islington Committees in

Common:

Strategy & Finance Committee

Quality and Performance Committee

There may be other committees that I

attend ex-officio

Sidney Estates Tenants and Residents

Association, Tower Hamlets

no no yes no Chair 21/06/2017 current 02/10/2018 05/08/019 Interest declared. Very low risk to current role.

Sorrel Brookes Lay Vice Chair &

Lay Member of Governing Body

Chair of:

Strategy & Finance Committee

Remuneration Committee

Primary Care Transformation Board

GP Federation Working Group

Member of:

Audit Committee, Islington CCG

PPP Committee

NCL Primary Care Committee

NCL Joint Commissioning Committee

Help on Your Doorstep no no Yes no Trustee 2017 current 23/08/2018 21/08/2019 Help on your doorstep is a contractor for

Islington CCG. I take no part in contracting

decisions.

Jennie Williams Director of Quality and Nursing Haringey

CCG & Islington CCGs and Registered

Nurse, Islington CCG

Voting member, Governing Body,

Haringey and Islington CCGs

Member, Quality and Performance

Committee, Haringey and Islington CCGs

Attend other meetings as and when

required

None no no no no None 14/08/2019 14/08/2019

Date Of InterestType of Interest

Is th

e in

tere

st d

irec

t

or in

dire

ct?Description of interest

Nature of business/OrganisationNature of interest First Name Second name

Current position - ie Governing Body,

Member Practice, Employee or other

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Simon Goodwin Chief Finance Officer

Member, NCL CCG Governing Bodies

Member of all five CCG Finance

Committees

Attendee, CCG Audit Committees and

NCL Audit Committee in Common

Attendee, NCL Joint Commissioning

Committee

Attendee, NCL Primary Care Co

Commissioning in Common

East London Foundation Trust no no Yes Indirect Wife is a Senior Manager at the

Trust

14.6.2017 current 12/10/2018 08/08/2019

Sabin Khan Member of Governing Body

Clinical Lead for quality at Whittington

Health

Member of Quality & Performance

Committee

River Place Group Practice

Highbury Medical Services Ltd (07780706)

Islington GP Federation

Yes

YES

Yes

Yes

YES

Yes

No

No

No

Direct

Direct

Direct

Salaried GP and employee of

River Place Health Centre

Director/Shareholder - provider

of private medical services

Practice is a member

15/10/2018 current 15/102018 02/09/2019 The Federation has been established with full

support of ICCG and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process

Central 1 Primary Care Network yes yes no direct Practice is a member 01/06/2019 current 02/09/2019

Rathini Ratnavel GP Member of Governing Body (SE

Islington representative)

Member of Audit Committee, Mental

Health and Older Adults Lead,

Member of Strategy & Finance Committee

Overview of Adult Safeguarding.

Freelance GP working on a sessional

basis in Islington practices.

Sessional GP with I:Hub service, which

provides primary care services to Islington

patients

Marlborough House School, Kent

Field James Ltd construction company.

Yes

Yes

no

no

Yes

Yes

No

No

No

No

Yes

Yes

direct

direct

direct

indirect

Member of the Hurley Group

locum GP bank

Islington GP Federation

School Governor & Trustee

Spouse is sole Director of Field

James Ltd.

08/05/2018 current 11/07/2018 12/08/2019 The Federation has been established with full

support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process

GP Member Governing Body

Member of Medicines Management

Attendee at IMOG

Community Services Improvement Group

Andover Medical Centre (AMC) Yes Yes No direct 1. AMC provides the premises of

one of the hubs for I:Hub

2. • Dr Amita Varma – another

partner at AMC is on the

Federation Board.

• Nurse Daniela Gomes who is an

employee (practice nurse) at

AMC is also on the Federation

board

16/05/2017 current 11/07/2018 12/08/2019 1. Service model is approved by NHS

England.

Islington GP Federation yes yes direct Practice is a member The Federation has been established with full

support of the ICCG and any business

conducted between commissioners and the

federation is subject to normal scrutiny and

probity. External auditors have advised the

CCG of appropriate process

Primary Care Project yes yes direct Clinical Lead

North Islington Primary Care Network yes yes direct Practice is a member 01/06/2019 current 30/06/2019 08/08/2019

Rue Roy

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Josephine Sauvage Chair of Islington CCG Governing Body

Co-Chair of A&E DeliveryBoard

Member of H&I Strategy and Finance

Committee

Member of NCL Urgent and Emergency

Care Delivery Board

Member of Islington HWBB

Member of Joint Haringey & Islington

HWBB

Chair of Haringey & Islington Community

Education Provider Network

Co-Chair NCL STP Clinical Cabinet

NCL CCG Chair representative on STP

Programme Delivery Board

Member of NCL Local Workforce Advisory

Board

SRO Primary Care workforce / new

models of care

City Road Medical centre

NHS Clinical Commissioning Board

Chair of Wellbeing Partnership

South Islington Primary Care Network

Yes

Yes

Yes

Yes

Yes

Yes

Yes

no

no

no

no

direct

direct

indirect

Direct

City Road Medical Centre is a

member of the Islington GP

Federation - The share is

formally held in the name of Dr

Philly O'Riordan, one of my

partners

The practice holds a single share

in the Islington GP Group Ltd

trading as Islington GP

Federation.

Board member

Practice is a member

02/02/2017

01/06/2019

current

current

06/11/2018

30/08/2019

30/08/2019 1. The Federation has been established with

full support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process

2. I am absent from any discussions or

decisions within my role as CCG Chair that

might overlap with my role as a member of

this organisation. I also am not privy to any

information that may create a conflict in my

role. The CCG has standard systematic

processes in place to ensure that this process

if appropriately enacted.

Karen Sennett CCG GP Governing Body member

Attendee at Quality & Performance

Committee.

Clinical lead for cancer,

urology, neurology, COPD &

asthma.

Killick Street Health Centre

Islington GP Federation

South Islington Primary Care Network

Yes

No

Yes

Yes

No

Yes

No

yes

No

Direct

Direct

Direct

GP Partner

Practice is a member

Practice is a member

08/04/2016

01/06/2019

current 24/10/2018 09/08/2019 1. The Federation has been established with

full support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process

Deborah Snook Clinical Performance Manager,

Caldicott Guardian,

Islington GP Federation.

Practice Manager Representative on the

Governing Body.

I sit on the QIPP Delivery Group and the

Patient and Public Participation

Committee.

I contribute to other work-streams as

appropriate & necessary.

Attendee at the Primary Care

Transformation Board

Clerkenwell Medical Practice

Mornington Grove Housing Co-operative

Londonwide LMC Practice Managers

Leads forum.

Clerkenwell Medical Practice

Islington GP Federation

Rising Minds CIC

Deep:Black

Gynaecology Teaching Associates LLP.

y

n

n

n

n

n

n

n

y

y

y

y

n

n

y

n

n

n

n

y

y

direct

direct

direct

direct

direct

indirect

indirect

Employee

Member

Attendee

My GP practice is paid for my

time when I do Quality

Improvement Work for the

Islington QIST for which Islington

GP Federation currently hold the

contract.

Caldicott Guardian as of

10.09.2018. This is a salaried

position.

Friends of Director of Rising

Minds which has done work with

Haringey CCG

Friends with a director of Deep

Black

Friends with a director of GTA

15/04/2016 current 26/10/2018 29/08/2019 1. The Federation has been established with

full support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process.

Lucy De Groot Lay Member of ICCG Governing Body

Member of H&I Strategy and Finance

Committee

Chair of Audit Committee

Member of NCL Audit Committee in

Common

Chair of H&I Quality and Performance

Committee

Member of Remuneration Committee

meeting in common with other NCL

Remuneration committees

Member of NCL Assurance Group

Member of the NCL IFR Appeals Panel

Attend other committee meetings as

required

Baring Foundation

NPC(New Philanthropy Capital)

no

no

Yes

yes

no

no

direct

direct

Trustee

Trustee

11/07/13

13/12/17

current

current

04/07/2018 02/09/2019 Any perceived conflicts will be managed in line

with policy guidelines. Minimal risk as non of

these diretly active in NHS sector.

Page 8 of 131

Clare Henderson Director of Commissioning, Haringey CCG

and Islington CCG

Attend:

Governing Body, Islington CCG

H&I Strategy & Finance Committee

NCL Primary Care Committee in Common

no no no no no none 22/10/2018 current 22/10/2018 08/08/2019

Julie Billett Public Health representative, Governing

Body

Member of Haringey & Islington Strategy

and Finance Committee

Member of Joint Haringey & Islington

HWBB

Member of NCL STP Clinical Cabinet

SRO for Prevention Workstream of NCL

STP

Member of Camden CCG Governing Body

Director of Public Health, Islington Council

Chair of the London Association of

Directors of Public Health

no yes no direct Chair 21/02/2017 current 22/10/2018 09/08/2019 Interest declared. Very low risk to current role.

Ros Davies Healthwatch Healthwatch Islington representation at the

CCG Governing Body

no no no no none 01/10/2018 current 09/08/2019 09/08/2019 Ensure a declaration is made when any

relevant agenda item is discussed at meetings

Jessica McGregor Attendee at CCG Governing Body Director of Commissioning, Adult Social

Care, London Borough of Islington

no no no no none 10/05/2018 current 10/05/2018 02/09/2019

Sara Lightowlers Secondary care member of Governing

Body

Medical Director at Sussex Community

NHS Foundation Trust

no no no no secondary care consultant 22/101/2018 current 01/08/2019 08/08/2019

Will Huxter NCL Director of Strategy

Attendee at Governing Body for all 5

CCGs in NCL

n/a no no no no none 03/07/2018 current 03/07/2018 08/08/2019

Paul Sinden NCL Director of Performance, Planning &

Primary Care

Attendee at Governing Body for all 5

CCGs in NCL

Attendee of NCL Committees - Primary

Care and Joint Committee.

n/a no no no no none 30/04/2018 current 30/04/2018 16/08/2019

Katie Coleman Co-opted GP Representative in

attendance at Islington CCG Governing

Body

Chair of the PPP Committee

NCL STP lead for Primary Care and Care

Closer to Home

Chief Clinical Information Officer for

Islington CCG

Stakeholder Governor at UCLH

Co-chair of the connected Communities

working group across Islington CCG and

Isslington Local Authority

GP Partner City Road Medical Centre

I:Hub – a service run by Islington GP

Group Ltd

Islington GP federation Ltd

Royal College of General Practice.

University College London Hospital

(UCLH) NHS FT. NHS stakeholder

providing oversight

South Islington Primary Care Network

y

y

y

y

n

y

direct

direct

direct

direct

direct

direct

direct

GP Partner

provide services on a sessional

basis

Director of Federation

Clinical lead for Collaborative

Care and Support Planning

Stakeholder Governor

Practice is a member

18/04/2016

01/06/2019

current

current

11/07/2018

30/08/2019

09/08/2019 1. Service model is approved by NHS England

2. Non-voting GP member of the Islington

CCG Governing body. Will not attend part 2 of

the Islington Governing Body meetings. Does

not hold a position on any CCG decision

making committees.

The federation has been established with full

support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process.

Sarah Mcilwaine Programme Director, Care Closer to

Home, North London Partners (employed

by Islington CCG)

Governing Body non-voting membe

n/a no no no no none 09/10/2018 current 09/10/2018 05/08/2019 Ensure a declaration is made when any

relevant agenda item is discussed at meetings

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Clinical Director, Islington CCG y y n direct Clinical Director 07/11/2018 current 07/11/2018 02/08/2019

Member of the Executive Management

Team

y y n direct member 07/11/2018 current 07/11/2018 02/08/2019

Conflict of interest issues for the Governing

Body and CCG.

n y n direct Lead 07/11/2018 current 07/11/2018 02/08/2019

Caldicott Guardian for Islington & Haringey n y n direct Caldicott Guardian 07/11/2018 current 07/11/2018 02/08/2019

Freedom to Speak up Guardian for

Islington & Haringey

n y n direct Guardian 07/11/2018 current 07/11/2018 02/08/2019

Individual Funding Request Panel direct Chair 07/11/2018 current 07/11/2018 02/08/2019

Locally Commissioned Services Working

Group

direct Chair 07/11/2018 current 07/11/2018 02/08/2019

Islington & Haringey on the NCL Primary

Care Joint Committee

direct Clinical representative 07/11/2018 current 07/11/2018 02/08/2019

Supporting and managing the Clinical

Leads (including Darzi fellow) -

recruitment, bi-monthly network meetings,

appraisals, finance.

direct Support and manage 07/11/2018 current 07/11/2018 02/08/2019

Medicines and devices Safety Officer

(MSO & MDSO)

direct Safety Officer 07/11/2018 current 07/11/2018 02/08/2019

MSO/MDSO network for local CCGs and

Providers

direct Chair 07/11/2018 current 07/11/2018 02/08/2019

Controlled drugs safety lead and

Antimicrobial stewardship lead.

direct Lead 07/11/2018 current 07/11/2018 02/08/2019

Whittington Care Quality Review Group

n direct member 07/11/2018 current 07/11/2018 02/08/2019

Map of medicine team

direct Provide clinical leadership 07/11/2018 current 07/11/2018 02/08/2019

Serious incident reviews & patient safety

direct Provide clinical leadership 07/11/2018 current 07/11/2018 02/08/2019

GP Practice Quality

direct Provide clinical leadership 07/11/2018 current 07/11/2018 02/08/2019

Pressure ulcer task and finish group.

direct Provide clinical leadership 07/11/2018 current 07/11/2018 02/08/2019

Federation Working Group

direct Provide clinical leadership 07/11/2018 current 07/11/2018 02/08/2019

Chair board Link visits direct Chair 07/11/2018 current 07/11/2018 02/08/2019

NLP IG Working Group direct Chair 07/11/2018 current 07/11/2018 02/08/2019

Locum GP y y n direct Tower Hamlets for surgeries

which are members of their

Federation.

07/11/2018 current 07/11/2018 02/08/2019

Locum GP y y n direct ad hoc sessions in various GP

surgeries across London,

excluding Islington.

07/11/2018 current 07/11/2018 02/08/2019

Novo Nordisk pharmaceutical company. n n n Indirect My Sister is a Medical Advisor 07/11/2018 current 07/11/2018 02/08/2019

St Helier Hospital in Sutton. n n n Indirect Partner is an ITU Consultant 07/11/2018 current 07/11/2018 02/08/2019

City and Hackney Local Medical

Committee

n y n direct member 07/11/2018 current 07/11/2018 02/08/2019

City & Hackney Urgent Healthcare Social

Enterprise -providing out of hours care for

City & Hackney CCG residents.

y y n direct I am a GP - I do shifts for the

Paradoc emergency home

visiting service.

07/11/2018 current 07/11/2018 02/08/2019

Communitas, a private provider seeing

NHS patients,

y y n direct I undertake clinical sessions in

my role as a GP with a Special

interest in ENT.

07/11/2018 current 07/11/2018 02/08/2019

Dominic RobertsIn Attendance

Page 10 of 131

Haringey CCG as an external GP y y n direct as an external GP on their

transformation group and

investment committee. I also

support some of their

procurement work streams and

other CCG duties as required as

an external GP.

07/11/2018 current 07/11/2018 02/08/2019

Babylon, a private provider for digital GP

consultations.

y y n direct locum GP. Babylon supports the

111 service in London.

07/11/2018 current 07/11/2018 02/08/2019

Hackney VTS GP training scheme y y n direct Programme director, employed

by the London Specialty School

of General Practice, Health

Education England.

07/11/2018 current 07/11/2018 02/08/2019

I am a GP Appraiser for the London area. y y n direct GP Appraiser 07/11/2018 current 07/11/2018 02/08/2019

I am a mentor for GPs under GMC

sanctions.

y y n direct GP Mentor 07/11/2018 current 07/11/2018 02/08/2019

I am currently mentoring a salaried GP at

a practice in Haringey.

y y n direct Salaried GP 07/11/2018 current 07/11/2018 02/08/2019

Clinical Vice Chair of Islington CCG

Governing Body

Islington Central Medical Centre y n y direct Salaried GP 11/01/2017 current 08/03/2018 09/08/2019

Primary Care & Integrated Care Lead Clinical Lead for CHINs y y y direct The practice holds a single share

in the Islington GP Group Ltd

11/01/2017 current 08/03/2018 09/08/2019

Children and Young Persons y y n direct clinical lead 11/01/2017 current 08/03/2018 09/08/2019

COG: CHIN Operational Group n y n direct Joint Chair 11/01/2017 current 08/03/2018 09/08/2019

Primary Care Strategy n y n direct Chair 11/01/2017 current 08/03/2018 09/08/2019

GP Forum n y n direct Chair 11/01/2017 current 08/03/2018 09/08/2019

Children's Services Improvement Group direct acting chair 11/01/2017 current 08/03/2018 09/08/2019

Clinical Leads meetings n y n direct attendee / member 11/01/2017 current 08/03/2018 09/08/2019

NCL Primary Care Clinical Reference

Group

n y n direct attendee / member 11/01/2017 current 08/03/2018 09/08/2019

QIPP Meetings n n n direct attendee / member 11/01/2017 current 08/03/2018 09/08/2019

Integrated Network Governance Group

and other meetings as they may arise

direct attendee / member 11/01/2017 current 08/03/2018 09/08/2019

Central 1 Islington Primary Care Network y n y direct Practice is a member 01/06/2019 current 09/08/2019 09/08/2019

monthly teleconference MDTs

Central Medical Centre

n y n direct chair 11/01/2017 current 08/03/2018 09/08/2019

Karl Thompson Senior Head of Corporate Services, NCL

SIRO for Haringey & Islingon CCGs

Attend all 5 CCGs

Governing Body meetings

Attend all 5 CCGs

Emergency Planning meetings

Occasional attendance at other NCL-wide

CCG committees and meetings

Chair of NCL IG Group meeting

no no no no no none 12/10/2018 current 09/08/2019 09/08/2019

Alex Smith Director of Planning and Delivery,

Haringey and Islington CCGs

Attendee of :

CCG Governing Body

H&I Strategy & Finance Committee

QIPP Delivery Group

no no no no no none 02/11/2018 current 02/08/2019 02/08/2019

Dominic RobertsIn Attendance

The Federation has been established with full

support of Islington Clinical Commissioning

Group (CCG), and any business conducted

between commissioners and the federation is

subject to normal scrutiny and probity.

External auditors have advised the CCG of

appropriate process.

Imogen Bloor

Page 11 of 131

Elizabeth Ogunoye Director of Acute Commissioning and

Performance Improvement

Attend CCG Governing Body

Member, Quality and Performance

Committee

Attendee, Strategy and Finance

Committee

no no no no no none 22/10/2018 current 05/08/2019 05/08/2019

Anthony Browne Deputy Chief Finance Officer, Haringey

and Islington CCGs

Attendee, Governing Bodies, Haringey

and Islington CCGs

Attendee, Strategy and Finance

Committees, Haringey and Islington CCGs

no no no no no none 23/10/2018 current 08/08/2019 08/08/2019

Ian Porter Director of Corporate Services for NCL

CCGs

Attends:

GB meetings for NCL CCGs

NCL Joint Commissioning Committee

NCL Audit Committee in Common

none no no no no none 12/10/2018 current 13/08/2019 13/08/2019

Eileen Fiori Director of Acute Commissioning for NCL

Member of NCL Senior Management

Team

Attends:

NCL Joint Commisioning Team

Finance & Performance Committees

Commissioning Committees across NCL

as and when required

none no no no no none 12/10/2018 current 12/08/2019 12/08/2019

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Page 1 of 7

Item: 1.5

Part One Draft Minutes Meeting of Islington Clinical Commissioning Group Governing Body

12 June 2019 between 9:30am and 11:00am Clerkenwell Room, 2nd Floor, Laycock PDC, Laycock Street, London, N1 1TH

Voting Members Present:

Dr Jo Sauvage GP Governing Body Member & Chair

Dr Imogen Bloor Clinical Vice Chair

Sorrel Brookes Lay Vice Chair

Simon Goodwin Chief Finance Officer, North Central London CCGs

Dr Sabin Khan Salaried / Sessional GP Representative

Dr Sara Lightowlers Secondary Care Consultant Representative

Helen Pettersen Accountable Officer, North Central London CCGs

Dr Rue Roy North Locality GP Representative

Dr Rathini Ratnavel South East Locality GP Representative

Dr Karen Sennett South West Locality GP Representative

Deborah Snook Practice Manager Representative

Jennie Williams Director of Quality and Nursing

Non-Voting Members Present:

Tony Hoolaghan Chief Operating Officer

Anthony Browne Deputy Chief Finance Officer

Clare Henderson Director of Commissioning

Sarah Mcilwaine Programme Director – Care Closer to Home

Julie Billett Director of Public Health for Camden & Islington

Elizabeth Ogunoye Director of Acute Commissioning and Performance

Paul Sinden Director of Performance, Planning & Primary Care, North Central London CCGs

Alex Smith Director of Planning and Delivery

In attendance:

Dr Katie Coleman Co-opted GP Representative

Jess McGregor Service Director of Adult Social Care, Strategy and Commissioning, Islington Council

Karl Thompson Senior Head of Corporate Services, North Central London CCGs

Steve Beeho Board Secretary, Haringey CCG

Observers:

Ros Davies Trustee, Healthwatch Islington

Apologies:

Lucy De Groot Lay Member, Islington CCG

Eileen Fiori Director of Acute Commissioning, North Central London CCGs

Will Huxter Director of Strategy, North Central London CCGs

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Page 2 of 7

1 INTRODUCTION

1.1 Welcome & Apologies for Absence

1.1.1 The Chair welcomed Governing Body members, attendees and members of the public to the meeting and in particular welcomed Ros Davies to her first Governing Body meeting.

1.1.2 Apologies had been received from Lucy De Groot, Eileen Fiori and Will Huxter.

1.2 Declarations of Interest Register

1.2.1

1.2.2 1.2.3

The Chair presented the current Governing Body declarations of interest register which is continually being updated in order to accurately reflect interests. The need to ensure that Governing Body members declare any fresh interests relating to Primary Care Networks (PCNs) was noted. Members of the Governing Body were then invited to declare any interests in respect to items on the agenda. No interests were declared. Action: To arrange for Governing Body members who work in a GP practice to update the Declarations of Interest register to specify what PCN their practice is in and whether they have a role in the PCN. (Vivienne Ahmad).

1.3

Declarations of Gifts & Hospitality

1.3.1 The Chair invited Members of the Governing Body to declare any gifts and hospitality received. No gifts or hospitality were declared.

1.4 Draft minutes of the previous Governing Body meeting on 13 March 2019

1.4.1 The Governing Body members considered the minutes of the meeting held on 13 March 2019 and noted that Sorrel Brookes’ name should be added to the list of people who had given their apologies in section 1.1.2.

1.4.2 Subject to the above amendment, the minutes of the Governing Body meeting held in public on 13 March 2019 were APPROVED as an accurate record.

1.5 Action log

1.5.1 1.5.2 1.5.3 1.5.4

The actions were reviewed and updated on the log sheet. It was agreed that actions 1-6 from the meeting on 13 March 2019 could be closed. The actions from the meeting on 9 January 2019 which had previously been closed could now be removed from the log, as could action 4 from the meeting on 12 September 2018. It was agreed that Steve Fothergill would be asked to provide an update on Docman and progress on the move to HSCN (Health and Social Care Network). Action: To ask Steve Fothergill to provide a briefing for Governing Body members and member practices on Docman and progress on the move to HSCN. (Tony Hoolaghan) The Governing Body NOTED the action log.

1.6 Matters Arising

1.6.1 There were no additional matters arising.

1.7 Questions from the Public

1.7.1 Three questions had been submitted in advance by Philip Richards. The responses were circulated to members and would be published on the CCG website after the meeting. It was confirmed that these answers were being replicated by the other NCL CCGs at their June Governing Body meetings.

2 OVERVIEW REPORTS

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2.1 Accountable Officer’s Report

2.1.1 2.1.2

Helen Pettersen presented the Accountable Officer's Report, outlining key work undertaken since the last meeting. She invited Sarah Mcilwaine to provide the following update on the development of PCNs:

There had been huge progress across London on the formation of PCNs within a very tight timescale. Practices had risen to the challenge, with the five CCGs working as one with the North London Partners in Health and Care Closer to Home programme to ensure a consistent approach to delivering the new GP contract.

This had also involved excellent partnership working with the LMC. Four PCNs have been established in Islington and three of the four clinical directors have been confirmed to date.

Although participation in the PCN DES (Directed Enhanced Service) was voluntary, all local practices had agreed to take part. Practices had all confirmed that they would like the GP Federation to support the PCNs.

Helen Pettersen then highlighted additional key points in the report:

The Quality and Performance Committee had asked the Governing Body to note the three bullet points in section 11.2 relating to the recently-approved multiagency safeguarding arrangements

To facilitate the implementation of a single NCL-level Child Death Overview Panel (CDOP) by September 2019, the Governing Body was being asked to delegate approval of the new CDOP arrangements to the Quality and Performance Committee

The Annual Report and Accounts 2018-19 had been approved by the Audit Committee in Common on 23 May 2019 and submitted to NHS England on 29 May

The CCG was saddened to report the death of Dr Judith Dixon, who had been a highly-regarded Islington GP for 37 years, before going on to become GP Medical Director for the Camden Primary Care Trust and subsequently Medical Director at Camden CCG. The Governing Body sent their best wishes to her family.

2.1.3 In response to a request for clarification about the lack of in-year financial savings resulting from the ongoing delay to the planned CSU in-housing, it was confirmed that the original plan was to achieve £1.4m saving across NCL over two years. It has now been agreed with the CSU that the NCL CCGs will receive the entire saving in 2019-20. The delay is part of a wider national issue and Sir David Sloman is taking this forward with NHS England.

2.1.4 The Governing Body:

NOTED the Accountable Officer’s Report and

DELEGATED the approval of the new arrangements for CDOP to the Haringey and Islington Quality and Performance Committee in Common.

3. FINANCE AND PERFORMANCE

3.1 2019/20 Financial Operating Plan Update

3.1.1

Simon Goodwin introduced the report, making the following points:

In line with the earlier delegated approval, Islington CCG and the other NCL CCGs had submitted their revised Operating Plans in mid-May

Overall, the combined NCL position improved from £59m deficit to £41m deficit

Islington CCG’s original share of this was £5.3m deficit but in the final submission the CCG committed itself to breaking even, the only NCL CCG to do so

The two major components of this were releasing the contingency that the CCG held and a review of planned investments

In agreeing to the release of this contingency, NHS England had recognised that none of the CCGs would have any ‘cover’ if their financial positions deteriorated in-year

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A block contract has been agreed with UCLH, which eliminates the risk of in-year overperformance but also means that the CCG does not have the ability to make further savings during the financial year

The contract agreed with Whittington Health is the only Payment by Results (PbR) contract in NCL. This is not considered a risk as the Trust generally performs in a predictable way

The remaining major contracting are largely ‘block’ in nature

The total gross QIPP plan for Islington amounts to £14m, including just over £1m of incremental investment in order to achieve net QIPP of £13m. It is crucial that the CCG achieves this in order to break even

The risk and mitigations set out are significantly smaller than in previous years, due to much of the risk having been ‘capped’.

3.1.2 The Governing Body then discussed the report, making the following comments:

Confirmation was sought on whether there are mitigations in place if waiting times at UCLH increase

PbR contracts were originally introduced when waiting times were significantly higher. A considerable amount of work is currently taking place regarding outpatient transfers and improving the capacity for elective pathways, and an NCL RTT (Referral to Treatment) Delivery Group has been set up to provide mutual aid through a more collaborative approach

The current Whittington Health contract was a ‘pure’ PbR one, whereas in the two previous years a PbR contract with marginal rates to partly mitigate against in-year overperformance had been agreed

Under the ‘cap and collar’ contracts agreed with NMUH and the Royal Free, the CCG pays a particular amount for overperformance and nothing if performance exceeds this and the CCG receives money back if there is underperformance up to a certain point

Ideally the CCGs would have liked to move the Whittington Health contract to a cap and collar one as well, but the premium that the Trust was seeking made this option financially unattractive

It was clarified that although the acute contract with Whittington Health is a PbR one, the Community Services contract is a block contract.

3.1.3 The Governing Body NOTED the 2019-20 Financial Operating Plan and the risks within it.

3.2 Performance Report

3.2.1 Elizabeth Ogunoye presented the Performance report and highlighted the following points:

The Whittington Health A&E Delivery Board had agreed a new approach to managing urgent and emergency care pressures and improving and standardising processes for patient assessment, admission and discharge. This new approach is currently being tested and the initial feedback from the Trust on this more collaborative way of working has been broadly positive

The Community Services transformation work is ongoing, with improvements being reported in podiatry waiting times and MSK routine and clinical assessments

Plans are in place to review Community Services where there have been variations in performance to identify the ‘drivers’ and agree appropriate actions

Good performance has been reported across the key mental health standards

Progress is being made in the implementation of the Whittington Health CAMHS remedial action plan to achieve its Referral to Treatment (RTT) target of 8 weeks by December 2019.

3.2.2 The Governing Body then discussed the report, making the following comments:

Concern was expressed about the reported underperformance against the national standard for physical health checks for people with severe mental illness. It was

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Page 5 of 7

suggested that it was likely that this reflected under-recording, rather than the health reviews not being carried out, but confirmation would be provided outside the meeting

It was clarified that the NCL CCG CHC Transformation Business Case which the Strategy and Finance Committed had approved in February 2019 had not progressed as it had not been approved by all five CCGs. The CCG is in the meantime working closely with Whittington Health and Islington Council to improve performance to meet the standard

The improvement in podiatry performance was welcomed. This was primarily attributed to the Community Services internal improvement work, focusing on processes and workforce issues

It was also recognised alongside this work that there is a need for sustainable processes to be fully embedded to improve bladder and bowel performance, rather than over-relying on individuals

It will be crucial for the CCG to maintain a forensic grip on performance and quality through local assurance during a future period of transition

It was confirmed that the 2019-20 Quality Premium has not yet been published. It was agreed that it would be shared with the Islington GP Federation as soon as it is available.

3.2.3 The Governing Body NOTED the content of the report.

3.2.4 3.2.5

Action: To provide an update on the local performance against the national standard for physical health checks for people with severe mental illness. (Clare Henderson) Action: To share details of the 2019-20 Quality Premium with the Islington GP Federation when it is published. (Jennie Williams)

4. GOVERNANCE

4.1 Board Assurance Framework

4.1.1 Alex Smith presented the Board Assurance Framework (BAF), noting the following points:

The appropriate risk registers had been reviewed by the Committees and feedback had been incorporated

Risks on the BAF currently have a score of 12 or higher but in line with the new risk management policy, only risks with a current score of 15 and above will be presented to the Governing Body with effect from the next meeting in September 2019. This will enable it to focus its time and attention on the most serious risks

The CCG has seven open risks on the BAF

The three highest-rated risks (439, 440 and 441) are inter-connected as they all relate to the CCG meeting its 2019-20 Financial Control Total

Two risks relating to the previous financial year had been closed since the last meeting.

4.1.2 Jennie Williams provided a verbal update on Risk 423, which relates to the risk of the agreed specification for the Lower Urinary Tract Symptoms (LUTS) not being met. She noted the following:

The CCG is supporting the trust’s intention to implement the revised protocol for the adults LUTs service following assurance that the Trust’s Drug and Therapeutics Committee and interim Medical Director have given approval. Given that the CCG is not a tertiary commissioner and the drug regimen is not NICE compliant, NHS England/Improvement has advised that an expert opinion on the protocol should be secured.

The Haringey and Islington Quality and Performance Committee in Common will consider the outcome of the expert opinion on behalf of the NCL Joint Commissioning Committee. On the advice of the regional Medical Director, NHS England/Improvement, the CCG has approached the Royal College of Physicians regarding an appropriate expert and is awaiting a response.

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Page 6 of 7

Regarding the children’s service, the tertiary pathway for LUTS continues to be Great Ormond Street Hospital for Children NHS Foundation Trust. The Regional Medical Director NHS England/Improvement is meeting with the families of children who remain dissatisfied with the pathway on 4 July 2019 to explain the outcome of his discussions with national experts. The CCG has been invited to join the meeting.

4.1.3 The Governing Body then discussed the report, making the following comments:

It was agreed that Ian Porter would be asked to formulate an NCL-wide risk relating to the proposed transition to ‘future-proof’ the Register to reflect the changing landscape

It was recommended that the score the risk relating to acute activity (Risk 439) should be reduced from 20 to 12 in the next review.

4.1.4 The Governing Body NOTED the content of the report. Action: To ask Ian Porter to formulate an NCL-wide risk relating to the proposed transition. (Alex Smith)

4.2 Joint Individual Funding Requests (IFR) Appeals Panel - Terms of Reference

4.2.1 4.2.2

4.2.3

4.2.4 4.2.5

Andrew Spicer introduced the paper. He noted that when NHS Barnet, Enfield, Haringey and Islington CCGs agreed in November 2018 to form a joint panel to make decisions on IFRs, it was recognised that further work would be required on the IFR Appeals Panel Terms of Reference. The Terms of Reference have now been developed which incorporate strengthened governance arrangements and additional protection from Judicial Review. This report also provided a clarification to the IFR Panel’s Terms of Reference, making it clear that the GP representatives can include senior directors and/or other clinicians who are GPs who are standing attendees at Governing Body meetings rather than full voting members. This enables Dominic Roberts, Medical Director, Islington CCG, to be one of the CCG’s representatives on the panel. The following comments were made by Governing Body members:

It was clarified that the Appeals Panel will only review the process followed by the IFR Panel.

It was confirmed that there have not been any appeals for a considerable period of time

It was confirmed that an Equalities Impact Assessment had been undertaken

It is imperative that members of the public are aware of the appeals process, especially in light of the recent changes to the PoLCE (Procedures of Limited Clinical Effectiveness) Policy, which is due to be renamed in recognition of the fact that the existing terminology is a misnomer

It was clarified that the committee will review its effectiveness annually, in accordance with standard practice. This would be made more explicit in the next update of the policy.

The Governing Body discussed the membership of the IFR Appeals Panel. It was noted that the voting membership of the IFR Panel and the IFR Appeals Panel should be different. Andrew Spicer confirmed that due to the principles of fairness and natural justice the voting memberships would be different. He agreed to clarify this in the IFR Appeals Panel Terms of Reference.

The Governing Body APPROVED the Terms of Reference.

4.3 NCL Joint Commissioning Committee (JCC) Terms of Reference

4.3.1 4.3.2

Andrew Spicer provided an overview of the proposed revisions to the NCL JCC’s Terms of Reference and Standing Orders following their annual review by the JCC at its April 2019 meeting.

The following comments were made by Governing Body members:

It would be helpful if amendments could be highlighted when revised documents are brought for approval in future

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4.3.3 4.3.4

Consideration would be given to removing the references to an Independent Chair in section 12 of the Standing Orders in the next review

It was agreed that as part of the next review it would be made clearer in Section 4 of the Standing Orders that meeting papers are published online. Andrew Spicer confirmed that they are currently published on line as it is standard practice but will expressly state this in the next review of the Terms of Reference.

Paul Sinden noted that a question had been raised by a member of the public on the deadline for deputations when there is a public holiday. Paul Sinden confirmed that the NCL JCC Terms of Reference would be amended to provide flexibility on the deadline when it is a public holiday or if the papers are published late.

The Governing Body APPROVED the revised JCC Terms of Reference and Standing Orders.

4.3.5 Action: To incorporate into the next review of the JCC Standing Orders the requirement to state that meeting papers are published online. (Andrew Spicer)

4.3.6 Action: To consider removing the references to an Independent Chair in section 12 of the JCC Standing Orders in the next review. (Andrew Spicer)

5. ITEMS FOR INFORMATION AND ASSURANCE

6.1 Minutes of the Quality & Performance Committee meeting of 26 February 2019

6.1.1 The Governing Body NOTED the minutes.

6.2 Minutes of the Patient and Public Participation Committee meeting of 10 January and 7 March 2019

6.2.1 The Governing Body NOTED the minutes.

6.3 Minutes of the Strategy & Finance Committee meeting of 28 February 2019

6.3.1 The Governing Body NOTED the minutes.

6.4 Minutes of the NCL Joint Committee meetings of 7 February, 7 March, 4 April and 2 May 2019

6.4.1 The Governing Body NOTED the minutes.

6.5 Minutes of the NCL Primary Care Joint Committee meeting of 21 February 2019

6.5.1 The Governing Body NOTED the minutes.

6.6 Minutes of the NCL Audit Committee in Common meeting of 16 January 2019

6.6.1 The Governing Body NOTED the minutes.

6.7 Minutes of the Committees in Common meeting of 24 April 2019

6.7.1 The Governing Body NOTED the minutes.

7 ANY OTHER BUSINESS

7.1 There was no other business.

7.2 Date of Next Meeting is Wednesday, 11 September 2019 between 9.30am and 11.30am.

These minutes are agreed to be a correct record of the Part 1 meeting of the Islington Clinical Commissioning Group Governing Body held on 12 June 2019. Signed:……………………………………Date:…………………………. Dr Jo Sauvage, Chair, Islington Clinical Commissioning Group

Page 19 of 131

Meeting Date Action No.Minutes

ReferenceAction Lead Deadline Update

12.06.19 1 1.2.3 To arrange for Governing Body members who work

in a GP practice to update the Declarations of

Interest register to specify what PCN their practice

is in and whether they have a role in the PCN.

Vivienne Ahmad Sep-19 08.08.19 - the declaration document has been

updated to include reference to PCNs and we

have commenced the annual refresh of

declarations for all key parties.

12.06.19 2 3.2.4 To provide an update on the local performance

against the national standard for physical health

checks for people with severe mental health illness.

Clare Henderson Sep-19 26.07.19 – The issue appears to be one of data

capture – further investigation and action is

underway to ensure that health checks carried out

by the SMI nurse and in primary care are being

captured and fed through into the performance

figures. These figures appear to capture only

those healthchecks that have been carried out

within the Integrated Practice Unit and therefore

under reports our position.

12.06.19 3 3.2.5 To share details of the 2019-20 Quality Premium

with the Islington GP Federation when it is

published.

Jennie Williams Sep-19 10.07.19 - The 2019/20 CCG Quality Premium has

yet to be published . The GP Federation will be

able to access via NHSE website once it is

released. Recommend to close this action.

12.06.19 4 4.1.4 To ask Ian Porter to formulate an NCL-wide risk

relating to the proposed transition.

Alex Smith /

Andrew Spicer

Sep-19 10.07.19 - This is being formulated and will be

included in the NCL Risk Register that is

presented to each Governing Body meeting. 

Recommend to close this action.

12.06.19 5 4.3.4 To incorporate into the next review of the JCC

Standing Orders flexibility for the deadline for

deputations in the event of Bank Holidays and

make it clearer that meeting papers are published

online.

Andrew Spicer Sep-19 10.07.19 - The NCL JCC TORS have been

amended to allow for flexibility in the deadline

when the papers goes out late or it is a bank

holiday.

12.06.19 6 4.3.5 To consider removing the references to an

Independent Chair in section 12 of the JCC

Standing Orders in the next review.

Andrew Spicer Sep-19 10.07.19 - This will form part of the next review of

the NCL JCC Terms of Reference. 

ACTION LOG: PART 1: Islington CCG Governing Body - 11 September 2019

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Meeting

Date

Action

No.

Minutes

ReferenceAction Lead Deadline Update

12.09.18 03 1.4.5 IT issues - To provide

an update on Docman

and the lack of clarity

about N3 to HSCN

move.

Steve Fothergill

/ Tony

Hoolaghan

Sep-19 10.07.19 -

DOCMAN – 12 sites have now gone live with DocMan 10 with a

further 8 booked in. The remaining sites are in the process of being

booked.

HSCN – 20 sites have now gone live with HSCN with no further sites

currently booked. We are currently overcoming a number of civil

works issues around a number of sites before the upgrade can take

place.

12.06.19 - To ask Steve Fothergill to provide a briefing for GB

members and member practices on Docman and progress on the

move to HSCN.

04.03.19 -

CAS - All responses have now been received by NHSE.

DOCMAN - Elizabeth Avenue has now successfully gone live with

DocMan 10 following a short pause whilst we responded to the CAS

alert.

HSCN - Site surveys and fibre work are ongoing. First site (City

Road) going live on the 28th February with Clerkenwell Medical

Practice going live shortly after. Further critical sites are being

prioritised.

ACTION LOG: PART 2: Islington CCG Governing Body - 12 June 2019

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Islington Clinical Commissioning Group Governing Body Meeting 11 September 2019

Report Title Accountable Officers Report

Date of report 04 September 2019

Agenda Item

2.1

Lead Director /

Manager

Not applicable Tel/Email

GB Member Sponsor

Not applicable

Report Author

Helen Pettersen, Accountable Officer for Barnet, Camden, Enfield, Haringey and Islington CCGs & NCL STP Convenor

Tel/Email h.pettersen@nhs.net

Report Summary

The Accountable Officer’s report highlights key issues for the Governing Body’s consideration that are not covered elsewhere on the agenda.

Recommendation The Governing Body is asked to: NOTE the contents of the report

Identified Risks

and Risk

Management

Actions

Where applicable any risks are identified within the report.

Conflicts of Interest

There are no conflicts of interest arising from this report.

Resource

Implications

There are no direct resource implications, although areas described has

resource implications for the CCG.

Engagement

Engagement activities are highlighted as appropriate.

Equality Impact

Analysis

There are no equality impacts arising from this report.

Report History and

Key Decisions

This report is a standing item on the Governing Body agenda.

Next Steps None

Appendices None

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Accountable Officer Report

June to September 2019

1 Introduction 1.1 This report focuses on the key activities that the senior team and I have been involved in

since the last Governing Body meeting and a summary of the work progressed. 2.0 European Union EXIT update 2.1 Further to the preparatory work undertaken in the spring, the NCL CCGs have continued to

work with NHS England and Improvement to ensure our organisations and the providers we commission remain fully prepared in the event of the United Kingdom leaving the European Union on a ‘no-deal’ basis. An assurance exercise was undertaken at the end of August to ensure there is a key team in place in each organisation to oversee respective EU Exit preparations.

2.2 The CCGs’ resources remain in place to manage the readiness, assurance and

communications work required for EU Exit – and we await confirmation from NHS England on the date from which the full preparatory processes will restart. The CCG SRO for EU Exit will again be required to liaise with both CCGs and Trusts across North Central London.

2.3 An EU Exit workshop for the London-region has been organised for 19 September to provide

an update on the national preparations / requirements - and to understand and test the joint working arrangements / responsibilities that will be put in place.

2.4 Further updates will be provided, as required, to Governing Body members in the run-in to

31st October 3.0 Health Information Exchange 3.1 The Health Information Exchange (HIE) went live in Barnet and Royal Free London on 2nd

July 2019. Systems usage has been very good with no major reported issues since then. The first surgery joining has six GPs (two part time) and 6,900 patients, and following the duty of transparency patient information they had only 11 patients opt out of the joined-up record. Feedback from clinicians has been positive and they were able to outline specific benefits such as: time saving; reduced stress for the GP; enabling better decisions; saving unnecessary appointments and phone calls; and reduced delay, waiting and anxiety for patients.

3.2 A plan is now being developed to roll-out to all GP practices in Barnet by around the end of

September and a draft plan is in review to roll-out across all partners over the next year. We are in the latter stages of testing with UCLH which will be followed by an HIE roll-out in Islington. We have secured HSLI funding and engagement to connect BEHMHT, CIFT and NMUH as well as strong engagement with all providers.

4.0 Primary Care Networks 4.1 NCL commissioning leads are working closely to implement the new GP Contract

Framework. The opportunity to use the PCN DES to build integrated frontline delivery for enhanced and community-based health services, with a positive impact on ‘core’ general practice delivery.

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4.2 Since the last governing body meetings and AO report, all mainstream primary care practices

in NCL have been confirmed in 30 primary care networks. Thirty-nine clinical directors have been appointed to lead the PCNs. PCN proposals were formally approved at the June NCL Primary Care Committee in Common, where the excellent progress and partnership working across NCL were noted.

4.3 At the time of writing, discussions continue with NHS E/ I to make arrangements for two

specialist primary care services (Camden Health Improvement Practice, most of whose patients are homeless and many of whom have substance misuse problems, and the Special Allocations Service, which registers violent patients).

4.4 PCNs are very new and at different levels of maturity, depending on how well-established

the working relationships are between member practices and with other partners. Some have been collaborating on the same basis for some time, where other partnerships are much newer.

4.5 Thirty nine clinical directors have been confirmed and it will be critical for the clinical directors

and other key partners to be involved in determining their support requirements, in order to ensure the success of our PCNs. We are supporting the clinical directors and PCNs to determine requirements for new (five-year recurrent) organisational and leadership development funding. Clinical directors have started to meet in individual boroughs, and will be coming together across NCL in early September by way of introduction and to discuss their support requirements.

CCG No.

PCNs

Barnet 7

Camden 7

Enfield 4

Haringey 8

Islington 4

5.0 Medium Term Financial Strategy 5.1 An oral update will be provided to ensure the meeting is provided with the most up to date

information. 6.0 Provider Contracts update 6.1 The Royal Free London contract has signature in place. 6.2 The UCLH Contract has been signed by NCL CCGs. There is a risk share on associate block

contracts which is being discussed by the Trust and North East London (NEL) Chief Finance Officers . This is expected to be concluded soon.

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7.0 The NCL Integrated Care System (ICS) and the Islington Borough Partnership 7.1 The Long Term Plan sets out the intention to develop integrated care systems across STP

footprints by 2021. NCL has established a design group with partner representation to co-

create an architecture, in particular, to agree what function sits where – at an ICS level, at a

borough level or at locality level. Good progress is being made on this.

7.2 At local level each CCG is now working with partners to bring together “Borough Partnerships”

that will plan and deliver services to their population (including those outcomes set by the

ICS).

7.3 We have established monthly meetings across the Islington health and care system to co-

produce our shared purpose and local arrangements for decision making. Early work

includes agreement to develop a prospectus and communications plan; a joint strategic

resource assessment that can understand spend across the system; and a focus on the

delivery of place-based integrated services through localities. Another priority is governance

and how this will need to change in order to be able to make shared decisions. To support

this we held an informal Health and Wellbeing Board seminar in July. This had senior level

representation from the Council, CCG and our partners and started testing some principles

for next steps.

7.4 In parallel, to the two work streams above, the NCL Corporate Services team together with

NCL Senior Management colleagues have been working through a due diligence process for

merger, which is overseen by NHS England at both London and national level. The

assurance process for merger is comprehensive and requires the preparation of multiple

documents to demonstrate the ability of the newly merged organisation to take on statutory

responsibilities of a public body. This work stream has required a significant amount of

capacity to meet the extensive assurance requirements.

7.5 Some aspects of the assurance requirements would still benefit from further clarification and

guidance, which will be incorporated in due course. The risks and benefits of progressing at

pace or slowing down to fully complete the due diligence assurance requirements have been

considered by NCL CCG Chairs and SMT.

7.6 To provide some additional time, it has been decided to convene an extra-ordinary Governing

Body meeting on 18 September 2019 to take the formal merger decision. Irrespective of the

formal merger decision, NCL CCG Chairs and SMT have reaffirmed their commitment to

realising the benefits of a single CCG and have agreed to operate in shadow form by moving

to a single operating model for 2020.

7.7 In the meantime, engagement with stakeholders and partners to design the new system at

borough and NCL level will continue, recognising the importance of quickly developing our

place based systems as the foundation for the NCL integrated care system.

Page 25 of 131

8.0 Adult Elective Orthopaedic Services Update

8.1 The Adult Elective Orthopaedic Services Review continues to progress well. In May 2019

the Joint Commissioning Committee of the five NCL CCGs approved the clinical delivery

model and options appraisal process and NHS providers of orthopaedic care in north central

London were asked to submit options for consideration that could meet the agreed model of

care.

8.2 In July 2019 an options appraisal process was held to consider the options put forward; the

panel included local commissioners and GPs and equal representation from patients and

residents. The purpose was to assess submissions against the status quo, using a scoring

system developed through a collaborative process.

8.3 An update is going to be taken to the Joint Health Overview and Scrutiny Committee in late

September and the NHS England assurance of the proposals will take place over the

autumn. The programme is on track to bring a pre-consultation business case for clinical

commissioner approval in mid-November and to formally ask for approval to go to public

consultation on proposed changes to the model of care later in November.

Helen Pettersen Accountable Officer 04 September 2019

Page 26 of 131

Islington Clinical Commissioning Group Governing Body Meeting 11 September 2019

Report Title Delivering the NHS Long Term Plan in North Central London: Developing our collective plans

Date of report

2 September 2019

Agenda Item

3.1

Lead Director /

Manager

Will Huxter Director of Strategy, NCL CCGs

Tel/Email 07960 873985 will.huxter@nhs.net

GB Member Sponsor

Helen Pettersen Accountable Officer

Report Author

Richard Dale Director of Programme Delivery

Tel/Email 07950 887838 richard.dale@nhs.net

Name of

Authorising

Finance Lead

Simon Goodwin Chief Finance Officer, NCL CCGs

Summary of Financial Implications

This paper sets out progress on the development of long term strategic plans which will have some implications for our financial plans, but these are yet to be quantified.

Report Summary

Earlier this year, across NCL, health and care system partners took part in a series of “Inter-great” events. These resulted in a consensus on the need to work together in new ways, building on the close working of our local NHS, councils and residents, to focus on delivering patient-centred care closer to home, based on individuals’ whole needs. The NHS Long Term Plan, published in January 2019, aligns closely with this direction of travel and current system transformation programmes. Developing a collective response to this provides an opportunity for us to work with partners to begin to design health services around residents’ needs, rather than organisations. These plans are currently a work in progress, and we now require the engagement and involvement of all local partners, stakeholders and residents over the next few months. In this time, they will also be cross-referenced, financially costed and refined for final agreement in November. This paper summarises the requirements of the NHS Long Term Plan, the high level approach being taken to developing collective plans and shares summaries of key areas for discussion.

Recommendation The Governing Body is asked to:

NOTE the alignment to current plans and direction of travel

COMMENT on the key questions posed on slide 15

SUPPORT the review of draft sections.

Page 27 of 131

Identified Risks

and Risk

Management

Actions

There is a need to engage with a wide range of partners and develop a shared coherent set of plans. As a result, a structured approach is set out in the document with draft plans being shared early on in the process. Work is ongoing to map interdependencies across the plans and ensure financial reconciliation takes place and this aligns with the development of the medium term financial strategy locally. This will be undertaken over the next two months ahead of endorsing the plan in November 2019.

Conflicts of Interest

Not applicable.

Resource

Implications

There are no direct resource implications for this paper, as it is not a project

proposal for additional internal resourcing, nor is it assuming additional external

resourcing. Work on the planning process is being taken forward as part of the

change programme management office.

Engagement

Engaging residents in the development of these plans will lead to better plans, more tailored to our local communities’ needs. We are working with Healthwatch as partners in engaging and involving local people in different ways as the plans develop. For the first phase (April to June): The five Healthwatch organisations across NCL were commissioned to undertake a range of engagement activities with residents, including a survey and series of focus groups. Headline areas coming out of this engagement include: access to services, patients being involved in decision-making, use of technology and access to information for residents. Phase two (July to September): includes further engagement across NCL and at a local level to engage with residents on these specific issues in more detail, as well as a detailed review of existing engagement work for gaps to understand where further conversations are needed. This will also include targeted engagement with specific seldom heard groups in each borough. Phase three (September to November): will be further engagement on our overall Long Term Plan and the London vision ahead of the full submission of our plan in November 2019.

Equality Impact

Analysis

No Equality Impact Assessment is planned or has been undertaken as part of the process for developing the Long Term Plan response itself. Once the plan is agreed it may be necessary to undertake EIA reviews for specific elements before they are implemented, where they mark a departure from current policies or approaches. This would be carried out in line with the current EIA approach.

Report History

and Key

Decisions

Not applicable.

Next Steps Following review and feedback from Governing Bodies and partners, the plans will be shared with Governing Body members in November for endorsement.

Appendices

None.

Page 28 of 131

Delivering the NHS Long Term Plan in North Central London: Developing our collective plans

Will Huxter, Director of Strategy NCL CCGs

September 2019

Page 29 of 131

Contents:

2

Section Slide

Purpose of paper 3

Alignment with existing work 4

Process for developing collective plans 5

Long Term Plan Implementation Framework 6

Alignment to the Medium Term Financial Strategy 7

Working with Local Authorities 8

Engaging with our residents on the plan 9

Approach to drafting sections 10

Requirements of section for consideration by CCG GBs 14

Key questions for consideration by CCG GBs 15

Appendices:

Appendix 1: Summary of sections for discussion and notes on drafts 15

Appendix 2: Fair shares and Targeted money 27-19

Appendices 3: Plan for engagement with residents 31 Page 30 of 131

Context and purpose of paper:

3

Building on local work with partners through the STP programmes, it is clear there is a collective commitment to deliver changes that will improve the health and wellbeing of residents living in Barnet, Camden, Enfield, Haringey and Islington (‘North Central London’).

Earlier this year, across NCL, health and care system partners took part in a series of “Inter-great” events. These resulted in a consensus on the need to work together in news ways, build on the close working of our local NHS and councils, with residents, to focus on delivering patient-centred care closer to home, based on individuals’ whole needs.

The NHS Long Term Plan, published in January 2019, aligns closely with this direction of travel and current system transformation programmes. Developing a collective response to this provides an opportunity for us to work with partners to begin to design health services around residents needs, rather than organisations.

These plans are currently a work in progress, and we now require the engagement and involvement of all local partners, stakeholder and residents over the next few months. In this time, they will also be cross referenced, finically costed and refined for final agreement in November.

This paper summarises the requirements of the NHS Long Term plan, the high level approach being taken to developing collective plans and shares summaries of key areas for discussion.

The board is asked to: • Note the alignment to current plans and direction of travel• Comment on the key questions posed on slide 15• Support the review of draft sections

Page 31 of 131

There a chance to build on existing, ongoing work

4

Following the Inter-great events held across North Central London, work has been progressing with partners to develop new ways of working with the aim of having the greatest positive impact for the health and lives of North Central London residents.

This work is developing collective plans for and integrated care system, which would a move to planning services based on populations and individuals rather than institutions to maximise the impact we can have. It will support the reduction of health inequalities across North Central London through working to support borough based integration of services to increase the focus on residents, communities and prevention.

This direction of travel is closely aligned to that set out in the NHS Long Term Plan and means as a system, we are well placed to use this opportunity to refresh plans in areas that may need strengthening or additional focus.

Following a review of the Long Term Plan requirements, it is clear that many of the ambitions and clinical priorities set out are already being progressed or are a logical next step for our current partnership programmes of work. For example:

• Developing integrated networks based around 30-50k population through our Health and Care Close to Home programme

• Simplification of UEC system across NCL • Radical transformation of planned care and outpatients

In addition, to this, the LTP’s strong focus on workforce and digital as drivers for change is reflected by the dedicated North Central programmes established locally to deliver change in these areas.

We want to work with partners to refresh plans to take account of the latest context and support the tangible changes required across the health system as we move to integrated care.

Page 32 of 131

In line with principles:

Clinically-led Locally owned involves realistic workforce

planning, Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards,

Is phased - based on local need.

In line with principles:

Clinically-led Locally owned involves realistic workforce

planning, Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards,

Is phased - based on local need.

In line with principles:

Clinically-led Locally owned involves realistic workforce

planning, Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards,

Is phased - based on local need.

In line with principles:

Clinically-led Locally owned involves realistic workforce

planning, Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards,

Is phased - based on local need.

Process for developing our collective plans

7

Existing STP and Org plans

Key themes from resident engagement

Local population

health profile

Requirements from LTP Plan

Critical system inputs:

Clinically-led Locally owned Realistic workforce

planning Financially balanced and

supports delivery of MTFS Delivers all LTP

commitments and national access standards

Phased - based on local need

Reducing health inequalities

Focussed on prevention Builds on existing work and

programmes and engages with Local Authorities

Drives innovation

Outputs of “Inter-great”

events

Plan sections drafted based on LTP implementation framework in line with principles:

Priority areas from

benchmarking

Drafted by authors, reviewed by clinical leads SROs and review groups (see slide 13)

NCL Delivery of NHS Long Term Plan

• Priority areas • Risks • Alignment with

organisational plans

Coordinated engagement with partners boards and resident on: North London

Partners

Improving health and wellbeing in NCL

Final plan for submission

• Interdependencies • Alignment with activity

and finance

Work to cross referencing sections for:

July and August Sept and October November

London Vision Drafts sections shared on websites for review by staff, partners and residents

Page 33 of 131

Long Term Plan Implementation Framework: summary

The LTP Implementation Framework (LTPIF) sets out the approach health systems are asked to take to create their plans. It included further details and information to help local system leaders refine their planning and prioritisation and detail about where additional funding will be made available to support specific commitments. It sets out the requirements in the sections listed below:

Seven sections on service changes. Two are national ‘fundamental service changes’ delivered in line with national timetables andtrajectories:

• Transformed ‘out-of-hospital care’ and fully integrated community-based care• Reducing pressure on emergency hospital services• Giving people more control over their own health and more personalised care• Digitally-enabling primary care and outpatient care• Better care for major health conditions: Improving cancer outcomes• Better care for major health conditions: Improving mental health services• Better care for major health conditions: Shorter waits for planned care• Increasing the focus on population health

Five section on the themes below. With Local freedom to set priorities / agree pace of delivery based on need; all LTP commitments must be delivered by the end of the five-years:

• More NHS action on prevention• Delivering Further progress on care quality and outcomes• Giving NHS staff the backing they need• Delivering digitally-enabled care across the NHS• Using taxpayers’ investment to maximum effect

https://www.england.nhs.uk/wp-content/uploads/2019/06/NHS-LTP-Implementation-Framework.pdf

7Page 34 of 131

Our plans must support the delivery of the Medium Term Financial Strategy currently being developed

The NCL Health system has an underlying deficit of £200m per year. Work is underway to develop a medium term financial plan which will outline the work needed to support the financial sustainability of the health service, with a plan across multiple years to reduce and remove costs out of the system through a set of collective actions across NHS partners.

The financial principles will need to underpin the deliver of the MTFS, which is plan is still in development but has the following emerging themes:

• Focus on organisational recovery plans in light of the constrained income environment • Reduce demand and activity growth particularly non elective • Limit acute trust income growth to less than 2% from 2020/21 - 2023/24 • Implementation of new models of care that support the three core themes above

These themes will need to be reflected in the NCL Long Term plan response.

7Page 35 of 131

Working with Local Authorities to develop plans

Working collectively with local authorities is critical to the delivery of changes that will improve the health and wellbeing of residents across North Central London.

To support us in developing these plans, we have worked with local authorities in the early stages of developing draft sections. We have done this through:

• Local authorities representatives have been involved in early system review groups to comment on and improve the draft sections

• We have had a dedicated Public health leads for all sections • Some of the section SROs are Local Authority senior leaders

In addition to this, over the next months, we will be working with local authority colleagues to review the drafts and develop the next iteration of these plans. We will do this through:

• Cross referencing the drafts against key themes of local authority plans strategic plans. • Review of the working drafts by senior Local Authority colleagues. • Review of sections by new borough partnerships, of which local authorities are a key member.

7Page 36 of 131

We are already engaging with our residents on plans

Engaging residents in the development of these plans will lead to better plans, more tailored to our local communities needs. We are working with HealthWatch as partners in engaging and involving local people in different ways as the plans develop.

For the first phase (April to June): The five Healthwatch organisations across NCL were commissioned to undertake a range of engagement activities with residents, including a survey and series of focus groups. Headline areas coming out of this engagement include: access to services, patients being involved in decision-making, use of technology and access to information for residents (please see next slide for these).

Phase two (July to September): includes further engagement across NCL and at a local level to engage with residents on these specific issues in more detail as well as a detailed review of existing engagement work for gaps to understand where further conversations are needed. This will also include targeted engagement with specific seldom heard in each borough.

Phase three (September to November): will be further engagement on our overall Long Term Plan and the London vision ahead of the full submission of our plan in November 2019.

7Page 37 of 131

The following themes from resident engagement will be used to guide the development of our plans:

From the HealthWatch surveys and focus group north central London residents told us about their priorities which we will include as themes throughout the sections of our plans:

• Increased access to services• Importance of involving patients in discussions and decisions about their care• Availability of clear and accessible information for patients, including easy read

versions and access to interpreters • Patients provided with the knowledge to keep themselves well and promote wellbeing• Integrated personalised care• Use of technology both to increase access to services and to health information• Better joint working between health and social care• Focus on prevention and early interventions• Everyone gets the same care, regardless of where they live

7Page 38 of 131

Approach to drafting sections: chapter authors, SROs and system review groups

To ensure local plans respond to the requirements of the LTP implementation framework, we are drafting sections to cover each of the sections of the framework. To support a system approach to these, we have identified an senior responsible officer, clinical care lead, author and a system review group for each one. In addition, we have also nominated a public health lead to support the drafting of these.

The outline of these roles is listed below and the individuals responsible for each section are detailed on the following slide.

Section SRO: A nominated senior lead responsible for ensuring the completion of the content for the section and the appropriate level of engagement as required across organisations. They are responsible for ensuring a system response, rather than an organisational one.

Clinical/Care Lead(s): A nominated clinical or care lead who can provide professional input into the clinical and care professional elements of the plan. They are responsible for ensuring the clinical and care models align with the direction of travel and the needs of local populations.

System Review group: This is the current system group – or specifically nominated group that contributes, develops and reviews the section. It does not have final sign off, so does not need to be representative of all organisations but its member should be confident that engagement has happened with the key organisations as required and the section aligns with the systems direction of travel.

Section author: This is the management lead nominated to draft the section based on the guidance from the change team. They will liaise with SROs, clinical leads and the review groups to draft the proposed content for the section. They will work with those identified by the review group to engage and test the sections ahead of submitting the section to the change programme team.

7Page 39 of 131

12

Theme SRO Clinical Lead(s) System review group Author Public Health Lead

Section 2 Delivering A New Service Model For The 21st Century: Themes And Leadership

Fully integrated community-based health care Tony Hoolaghan Dr Katie ColemanNominees from Health and Care Close to Home Board

Sarah McIlwaine Will Maimaris

Reducing pressure on emergency hospital services Sarah Mansuralli Dr Chris Streather, Dr Shakil Alam Nominees from STP UEC board Alex Faulkes Will Maimaris

Giving people more control over their own health and more personalised care

Kay Mathews TBC NCL CCG SMTShelia O’shea and Sarah D'Souza

Lilly Barnett Seher KayikciSue Hogarth

Digitally-enabling primary care and outpatient care John-Jo CampbellDrZuhaib Keekeebhai, Dr Cathy Kelly

STP Digital Board, STP planned care steering group

Martyn Smith Sarah Dougan

Improving cancer outcomes Paul Sinden Dr Clare Stephens Cancer Alliance Board Naser TarubiMary Orhewere, Aparna Keegan

Improving mental health outcomesSarah Mansuralli and Paul Jenkins

Dr Alex Warner, Dr Jonathan Bindman, Dr Vincent Kirchner

STP Mental Health Board Chris Dzikiti Tamara Djuretic

Shorter waits for planned care Paul Sinden Dr Dee Hora, Dr John ConnolleySTP Planned Care Steering Group and NCL Performance meeting

Edmund Nkrumah and Donal Markey

Glenn Stewart

Section 3 Increasing The Focus On Population Health

Moving to integrated care systems everywhere Will Huxter Dr Jo Sauvage, Dr Chris Streather NCL ICS design group Richard Dale Tamara Djuretic

Section 4 More NHS Action On Prevention

Focus on prevention Julie BilletDirectors Of Public Health/Public Health Consultants

Directors of public health Dr Hannah Logan -

Section 5 Delivering Further Progress On Care Quality And Outcomes

A strong start in life for children and young people Charlotte Pomery Dr Oliver Anglin STP Children’s Board Sam RostomSusan Otiti, Duduzile Sher-arami

Learning difficulties and autism Paul Sinden TBC NCL CCG SMT Kath McClinton

Better for major health conditions – Cardiovascular, Stroke, Diabetes, Respiratory

Will Huxter Dr Will Maimaris, Dr Julie Billet NCL CVD steering group, NCL Diabetes Group, NCL Respiritory group

Richard DaleWill Maimaris, Stuart Lines,Julie Billett

Research and innovation to drive future outcomes improvement

London wide section

Genomics London wide section

Volunteering Will Huxter Directors of nursing TBC Richard Dale -

Wider Social Impact and move to Population Health Will Huxter TBC TBC TBC Sarah Dougan

Section 6 Giving NHS Staff The Backing They Need

Feeding Back In Line With The Themes from the interim NHS People Plan

Siobhan Harrington Dr Jo SauvageSTP Workforce Steering Group and NCL Local Workforce Action Board

Sarah Young Tamara Djuretic

Section 7 Delivering Digitally-Enabled Care Across The NHS

Increase the use of digital tools to transform how outpatient services are offered and provide more options for virtual outpatient appointments

John-Jo CampbellDr Zuhaib Keekeebhai, Dr Cathy Kelly

STP Digital boardMartyn Smith and Hasib Aftab

Sarah Dougan

Section 8 Using Taxpayers’ Investment To Maximum Effect

Financial & Planning Assumptions, Improving Productivity and Reducing Variation

Simon Goodwin TBC STP Directors of Finance Gary Sired -Page 40 of 131

Key sections for discussion today:

13

The sections outlined below, have been highlighted for more detailed discussion at CCG Governing Bodies. This is because these areas: provide the opportunity to be more ambitious in rolling out best practice across NCL; potentially allow us to accessing additional funding; and will be critical in supporting the shift to health and care closer to home. Slides 19-26 summarise the draft sections of the plan with the requirements for these, listed below:

Developing a service model for the 21st century priorities: (See slide 18) • Developing Primary Care Networks (PCNs) as organisations, and building workforce and digital capacity to integrate services.• Introducing KPIs in community provider contracts to ensure consistency in implementing community health crisis response within 2 hours (from

20/21) and reablement care within 2 days (by 2023), building on existing good practice in some boroughs. • Strengthening anticipatory care with integrated services across health and care providers, building on effective models of practice of a number

of patient cohorts.• Implementing the enhanced health in care homes model to ensure consistency in service delivery by 23/24.

A focus on prevention: (See slide 21) • There is variation in local authority and health services for smoking, alcohol and obesity support, both in community and secondary care

settings. There is an opportunity to spread best practice across boroughs, and to bid for additional funding nationally to pilot new approaches before national rollout.

• We are continuing to build on wider system work on air pollution, AMR and targeting the obesogenic environment.

Improving outcomes in Mental health (see slide 23) • The plan build on the ambitions agreed at the NCL Expert by Experience programmes board, and the strategic priorities underpin delivery

against those, and align with the LTP priorities.• Work continues to progress with the provider development collaboratives (including a bid to NHSE re: delegating specialised commissioning

budgets), as well as work to stabilise and expand mental health community teams, particularly through expanding the workforce and implementing a new digital system

• Additional funding for mental health will be invested to expand access for services, including for CYP, perinatal and crisis care.• We have already been successful in securing pilot funding for some service areas and will continue to engage with NHSEI to make the case for

further funding in NCL to support local priorities in those areas. Page 41 of 131

Key questions for discussion today:

14

How we increase pace of change and rollout of best practice to ensure consistency across NCL in the development of PCNs and community services?

Are we happy to support bids for additional national funding and addressing variation across NCL with regards to prevention?

How do we best ensure increased investment aligned to the mental health investment standard supports the development of community services? Are we happy to support further bids for national funding?

Page 42 of 131

Next steps and ask of Governing body members

15

Stage Who Date

Discussion on key areas • CCG GBs 10-18 September 2019

Review of working drafts,shared on website of sections and feedback to section owners

• All partners 4 October 2019

Feedback received from partners and via resident engagement

• CCG Comms teams • Healthwatch• Partner resident

groups

4 October 2019

Review and endorsement of collated plan

• CCG GBs• NHS Trust boards • Borough Partnerships • HWBBs

November 2019

Page 43 of 131

16

Appendix 1: Summary of plans and links to working drafts

Page 44 of 131

Notes on drafts

The next slides summarise some of the sections in development – to support discussion at CCG Governing Bodies in September. In addition, we are making all of the full working drafts available on our website for review and comment. These can be found here: http://www.northlondonpartners.org.uk/ourplan/the-nhs-long-term-plan.htm

Please note:

• The documents are intended as a ‘system’ documents (i.e. a working draft to be shared between partners) which are in the public domain, rather than a document designed for the public. A public version will be developed as part of the next stage of the process.

• These sections build on local plans and are being shared early on with partners and in public in the spirit of transparency and for constructive comment and iterative development.

• These are the first working draft of the sections and are the output of discussion and debate through a series of system review groups.

• These sections have not yet been fully cross referenced with each other for interdependencies.

• These are yet to be fully costed and financially modelled although have been developed in line with current funding assumptions.

• This draft does not yet represent finalised policy positions. The document will undergo significant change through a series of drafting iterations.

7Page 45 of 131

Delivering a service model for the 21st century:

PCN development and building community capacityHealth and Care Closer to Home brings together system partners from primary, community, and acute services, local authority, commissioning and the voluntary sector via its Programme Board.

7

Development of PCNs

All mainstream primary care services are included in PCNs. There is now full coverage across NCL, with 30 PCNs (Barnet 7; Camden 7; Enfield 4; Haringey 8; Islington 4), based on geographical contiguity between practices; many are on the same footprint as the earlier CHINs/ neighbourhoods. As integrated care partnerships develop at borough level, community providers will configure teams on thesame footprints and develop a roadmap to ensure readiness to deliver the anticipatory care PCN DES specification from April 2020.

PCNs are at varying stages of maturity. Clinical Directors are currently diagnosing the support they will need to develop the PCN, which will inform how development funding is allocated. The emerging themes are:• Organisation development and change• Leadership development support (inc Clinical Directors)• Supportive collaborative working (MDTs)

Developing workforce and capacity in the community

Our NCL workforce programme, and specific Health and Care Closer to Home workforce action plan, describe our plans to develop, retain and recruit our workforce. We are using tools such as e-rostering, standardisation of shift patterns and the adoption of Care Hours per Patient Day to better understand our staffing requirements.

Our digital programme includes the introduction of a population health management approach, a health information exchange across NCL, and the development of a patient-facing digital record, and the development of digital and telephony-based services, which will increase capacity and support delivery of more efficient care In one borough, work is underway to align the community health care service system with that of GPs to include e-referrals, e-care plans and shared care planning. HealtheIntent is a local digital solution to support effective anticipatory care at a population level, which will integrate near real time data to deliver actionable analysis for anticipatory or proactive care.

• Population health management • Social prescribing and asset-based community development• Identifying, evaluating and sharing learning

Page 46 of 131

Delivering a service model for the 21st century: community crisis response and anticipatory care

7

Community health crisis response within 2 hours and reablement care within 2 days

We have established a crisis response model from 8am-8pm, 7/7, and are working with our three community providers to ensure a high degree of consistency including standard approaches to referral, eligibility criteria and operating hours. This is already being achieved in some boroughs, but not all. We will seek to include a standard contract KPI across the 5 boroughs from 20/21.

We are working with local authorities to ensure reablement care is delivered consistently within 2 days. Health-based communityreablement is delivered same day in some but not all of our boroughs currently. We are seeking to increase the speed that patients access community-based rehabilitation. A transition plan for contractual KPIs will see a shift from an expectation of a 2 week wait to a 2 day wait by 2023.

Bed-based rehabilitation has varied, and significant work has taken place to embed an effective Discharge to Assess model with an emphasis on ‘home first’. Further work is being undertaken in each borough with local authorities. Bed-based rehabilitation is often dependent on local authorities locating appropriate accommodation for patients deemed to require a supported care arrangement.

Anticipatory care by integrated primary and community services, together with local authority and voluntary sector providers

We have developed effective models of practice around a number of different patient cohorts (e.g. frailty, long term conditions, SMI), and each borough has developed MDT working with key elements of the health and care closer to home approach embedded (population segmentation / development of register, proactive case finding based on risk, outreach, care planning, MDT review and proactive case management, support to self care and self manage. Further work in 19/20 will develop the contribution of community providers, including caseloads, and operating policies. Some community health services are exploring operating from GP premises, including services for MSK, diabetes and asthma Self care is central to the plans. We have introduced the Patient Activation Measure (PAM) in one borough, focussing first on all care planned patients. This links to wider work on embedding the personalised care to spread best practice on the different elements of the universal personalised care model across NCL. We will further review the models of care as further detail of national specifications are published. Page 47 of 131

Delivering a service model for the 21st century: Enhanced health in care homes

7

Enhanced health in care homes

The 230 care homes in NCL are an important part of our health and care infrastructure, with care homes providing homes to 6,000 of our frailest residents outside of hospital (there are more care home beds than NHS beds in NCL). There is uneven distribution of care homes across NCL; around 90 care homes in Barnet (>70% of care home beds in NCL are in Barnet and Enfield), only 8 within Islington. There is a range of locally commissioned services for care homes across NCL, including GP in-reach, MDT support and a range of quality and workforce initiatives to support care homes. There are different models of care in each borough and some gaps, for example, benchmarking identified considerable variation in primary care input to care homes between boroughs, such as access to a named GP. NCL’s care home residents experience high acute admissions and LAS call outs, costing our CCGs £42m in 2017/18. This is above peer benchmarks and the London and national averages.

Working in partnership with the Local Authorities, NCL CCGs are working to join up health and social care and dedicated services in this area. The intention is to shift the reactive, expensive reliance on acute care, to a pro-active community based model that delivers betteroutcomes and meets the LTP ambition for consistent service delivery against the EHCH Framework by 23/24. This includes:• an innovative workforce programme that is supporting social care providers to recruit and retain staff, develop progression pathways

that increase staff skills and leadership capacity, which will support the NHS to meet the health care needs of care home residents.• actions that will support PCNs, including commissioning a care home dashboard to give us up to date information on activity

levels and quality; contributing to the development of the national PCN DES specification for EHCH, (some parts of NCL are likely to commission above this already).

• a Darzi fellow starting in September 2019 focusing on care homes to bring the system together to co-design and implement a new model for primary care input in line with the EHCH framework. This will strike a balance between standardisation of systems and processes, and necessary adaptation to local context, to address unwarranted variation.

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A focus on prevention:

Smoking and Alcohol

7

SmokingAround 14% of people across NCL smoke, varying from 10% in Barnet to 17% in Haringey. It is the single largest cause of health inequalities and premature death. There is significant variation in the availability and capacity of smoking cessation services; each borough commissions smoking services differently, both in the community and secondary care. Services are accessed through a range of providers, and residents can access the London-wide Stop Smoking portal.

We are developing a system-wide map of current investment, service delivery, and stop smoking activity and outcomes across secondary care providers in NCL, alongside LA-commissioned community cessation services to identify gaps and investment requirements, ranging from the identification of smokers, provision of brief advice, provision of pharmacotherapy, and onward referral into community stop smoking support. We are exploring opportunities to reduce variation through initiatives such as developing a NCL smoke free policy and options to standardise very brief advice training. Smoking in pregnancy has already been identified as a priority and a joint programme of work is being delivered by a partnership of maternity services, public health, service users, and stop smoking services across NCL.

AlcoholNCL has some of the highest rates of alcohol specific admissions in London with Camden and Islington significantly worse than London and England. Haringey, Camden and Islington also have some of the highest death rates for alcohol related mortality across NCL.

There are some excellent alcohol support services (including preventative and treatment services) across community, primary and secondary care, like commissioned online support (Barnet, Camden, Haringey and Islington), community outreach teams (Camden, Haringey and Islington), formalised detox and recovery services (Barnet, Camden, Haringey and Islington). The LTP highlights ACTs as being an effective approach to preventing alcohol related harm. Within NCL, services for alcohol liaison play a similar role to ACTs (in Camden, Haringey and Islington), funded by boroughs and situated in the local acute trusts, which are improving outcomes and a good return on investment. However, there is variation across NCL and where there are good services being provided, there are opportunities to upscale and reach a larger proportion of those in need.

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A focus on prevention:

Obesity, Air pollution and Antimicrobial resistance

7

ObesityBeing overweight is partly responsible for more than a third of all long term health conditions in NCL, with two of the five NCL boroughs (Enfield and Haringey) having a higher obesity prevalence (those with BMI of 30+) amongst 16+ than the London average. NCL’s National Diabetes Prevention Programme is now provided by a single provider, which includes a more comprehensive face-to-face behaviour change programme and a digital platform. Local public health teams will support general practice to maintain referrals into the programme and improve equity of access, particularly to reduce variation and inequalities with ‘at risk’ groups. Adults and children have access to NICE recommended Tier 1 and Tier 2 weight management support in four out of five NCL boroughs through community andprimary care initiatives, funded by local public health teams. There are no Tier 3 specialist support in NCL. We will look to develop a system business case for tackling this. There are system approaches targeting the obesogenic environment through sugar reduction, nutrition advice, physical activity schemes and promoting a healthy urban environment.

Air pollutionThe fraction of mortality attributable to air pollution particulate matters in NCL vary from 6.3% in Barnet to 6.9% in Islington, compared to 5.1% in England. Specific projects across NCL include work with schools, focus on Active Travel plans linked with local Transport Strategies and Local Implementation Plans, Healthy Streets approach, AirText messaging to residents that link with primary care, installing new electric charging points, and a health and care wide partnership on paediatric asthma pathways. Additional work will look at supporting NHS Trusts to sign up to the Clean Air Hospital Framework, and reduce business mileage and fleet air pollutant emissions.

Antimicrobial resistanceNCL CCGs are prescribing significantly below the national target of reducing antimicrobial use by 15% from the current national rate. Camden is the only borough achieving the target of broad spectrum antibiotics of less than 10% of the total antibiotics prescribed. 2018/19 AMR CQUIN data for NCL Trusts demonstrated improvements in total antibiotic usage - many found it difficult to reduce total carbapenem usage. The future focus will build on this and include: GP prescribing of broad spectrum antibiotics;healthcare associated Gram-negative blood stream infections and reducing UTI infections; evolving the Antimicrobial Pharmacists Group to become a multidisciplinary strategy group providing system wide leadership; establishing and improving antifungal stewardship; education & training; scoping work with all providers to support delivery.

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Improving mental health outcomes (i)

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AmbitionsNCL’s vision for mental health support is based on the principles established by our Expert by Experience Board. The ambitions are:• Improved access to care and support (embedding “no door is the wrong door”; addressing significant areas of unmet need; provide

support in the interim where people are on waiting lists for complex care treatment,; better coordination of access to specialist support once patients are discharged from secondary care, and develop fast track access to specialist mental health teams in a crisis)

• Service provision and development (reducing variation in support services; a greater community support offer and Crisis Cafes; stronger support and funding for the Voluntary and Community Sector, while subject to the same outcome measures as statutory services; transparency in addressing gaps in service provision and supporting people who require “complex care/the level above IAPT but below crisis intervention”, expanding the workforce particularly peer support roles)

• Outcomes and monitoring (increased focus on patient-centred goals like patient recovery outcomes, housing and employment, patient and public participation in evaluation and monitoring of services)

Strategic approach• Provider collaboratives: there are three NHS Provider Collaboratives in development that are aiming to take over NHSE Specialised

Commissioning budgets. The main objectives are to ensure: care closer to home through the elimination of external placements;incentives for community care; joined up pathways with secondary / primary care; providers in North London working as a system not in competition. All three have had their interview with NHSE following the first stage of the approval process and are awaiting feedback. If they progress into the fast track, they will need to submit a final business case by November with a start date of April 2020. They will be engaging with local authorities, CCGs and the NCL Transforming Care Partnership.

• Stabilising and expanding community teams: (i) implementing a new digital system across NCL, including a registry for physical health checks for adults with Serious Mental Illness, and automating identification of GP practices with low completion rates of healthchecks for this cohort, improving the support available for these practices and their patients through existing QUIST initiatives; (ii) expanding primary care workforce and further upskilling, including links to specialist support from mental health trusts, enabling the expansion of health checks and looking at further evidence of effective interventions that can be facilitated in part with Personal Health Budgets for this group; (iii) Individual Placement and Support services are available across NCL. The access standard for Early Intervention in Psychosis is already met across NCL and Service Development and Improvement Plans are now in place to ensure all services achieve Level 3.

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Improving mental health outcomes (ii)

7

• Initiatives via additional fair share funding to expand access: • CYP aged 0-15 services: NCL has good examples to learn from, including an open access / voluntary service models called ‘HIVE’ in

Camden and ‘Choice’ in Haringey, with principles, which could be replicated across the STP. • access to specialist community perinatal mental health services: NCL is collaborating to deliver a specialist community perinatal

mental health service for women with severe or complex mental health needs. Evidence-based care pathways operate locally and there are examples of initiatives that continue to inform the development of the new service, which will continue to focus resources and engage people who find help harder to access including teenagers and mothers from some BME groups including those for whom English is not their first language.

• 24/7 adult crisis resolution and home treatment teams (CRHT): there is 100% coverage of CRHT services which operate on a 24/7 basis and include Crisis Single Point of Access functions in addition to Home Treatment and Assessment teams. Camden and Islington also have a specialised Older Adults Home Treatment Team. CRHT provision will be able to deliver a high-fidelity service by 2021, maintain high-fidelity coverage of UCL Core Fidelity scales to 2023/24. There is a commitment to review Crisis Pathways inBEH; strengthening CRHT Teams and providing care closer to home will be critical to managing the increasing pressures on inpatient beds and to reducing out of area placements.

• CYP mental crisis services: NCL will develop a local integrated pathway for children and young people with higher tier mental health needs, including rapid community-based and out-of-hours responses to crisis. Investment will focus on expanding the crisis workforce and training for the crisis response team, with a focus on Dialectical Behaviour Therapy (DBT).

• Alternative crisis provision: current provision across NCL is varied. The planned transformation funding will evolve alternative crisis services to become increasingly uniform and equitable across the STP to all age groups for people, and their carers.

• Initiatives via additional targeted funding allocations (to be agreed with NHS England and NHS Improvement): • Salary support for IAPT trainees: IAPT trainee numbers have been agreed across NCL, with contract variations in place to

provide salary support in line with regional funding requirements.• CYP mental health support teams: all five boroughs in NCL had successful bids for Mental Health Support Teams

in schools trailblazer sites. Camden and Haringey went live in late 2018, Enfield go live in September 2019, and Islington and Barnet will go live in January 2020.

• Maternity outreach clinics in 2020/21 and 2021/22 Page 52 of 131

Improving mental health outcomes (iii)

7

• Initiatives that could be funded via additional targeted funding allocations (to be agreed with NHS England and NHS Improvement): • New models of integrated primary and community care for adults and older adults with SMI: this is central to the joint clinical

strategy by our mental health trusts over the next six months. Developments in community provision will continue over the next two years through transformation funding, using devolved specialised commissioning budgets, and expanding Primary Care MentalHealth services across NCL.

• Mental Health Liaison Services: these are delivered 24/7 in all 5 Acute sites in NCL, with a commitment to consolidate and expand MHLS. Partners have adopted a MHLS Collaborative Agreement, Core 24 service specification and associated KPIs. This system wide approach has attracted Wave 2 MHLS transformation funding to enhance provision and ensure all hospitals in NCL meet Core24 Standards for adults and older adults by 2021.

• Individual Placement Support (IPS): services are available across NCL following close working between health and social care, and a further two-year expansion will be supported through Wave 2 funding to extend access in primary and secondary care.

• Testing of clinical review of standards in 2019/20 (TBC)• Model for problem gambling: NCL was not successful in securing problem gambling funding in 19/20. It is considered a future

ambition due to established existing services and ability to expand the model. • Specialist Community Forensic Care and women’s secure: North London Forensic Consortium will be a wave 2 pilot site for the

new specialist community forensic team model, which will be rolled out over a 2-3 year period, initially covering Barnet, Enfield and Haringey, expanding to Camden and Islington from 2022/23. It will support development of accommodation pathways by co-commissioning housing providers, which will reduce length of stay for forensic inpatients, improve housing pathways and increasecommunity resource.

• Enhanced suicide prevention initiatives and bereavement support services: NCL successfully bid for PHE funding to develop a post-intervention suicide bereavement support service. Procurement will take place by March 2020.

• Mental health services to support rough sleepers: Haringey is a national pilot site and has taken an integrated multi-disciplinary approach to co-produce services for rough sleepers. It will integrate existing homelessness services in a co-located outreach teams. It will further integrate with health services (including GPs, Psychiatrists and Psychologists, occupational therapists, peer support workers) and integrated substance use treatment pathways to ensure effective holistic support. An MDT led by public health developed a funding proposal for Camden and Islington but was unsuccessful. It is a priority for future funding.

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26

Appendix 2: • Summary of the Long Term Plan

• Fair Shares allowances• London Vision

Page 54 of 131

Headlines from the NHS Long Term Plan (Jan 2019)

The NHS will increasingly be:• more joined-up and coordinated in its care• more proactive in the services it provides• more differentiated in its support offer to individuals.

Five major, practical changes to the NHS service model over the next five years:• Boost ‘out-of-hospital’ care and reduce primary and community health services divide• Redesign and reduce pressure on emergency hospital services• People will get more control over their own health, and more personalised care• Digitally-enabled primary and outpatient care will go mainstream across the NHS• Local NHS organisations will increasingly focus on population health and local partnerships with

local authority-funded services, through new Integrated Care Systems (ICSs) everywhere.

The NHS Long Term Plan describes transition to Integrated Care Systems. This would be supported by a single CCG in the North Central London area.

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Fair shares allocations and Targeted funding

The framework sets out the national funding which will be allocated to systems on a fair shares basis and provides an indication of the national total for targeted funding, to support specific projects.

The details of the requirement linked to the fair shares distribution and targeted funding are on the following slides.

System plans must set out how they will use their resources to deliver the commitments within the NHS long-term plan and meet the financial tests set out within it. This will include detail on the NCL Medium Term Financial plan required as the NCL system is in deficit.

Plans must also incorporate system actions to maximise efficiencies and support appropriate reductions in growth of demand.

In addition, spending plans must be consistent with the commitments to increase investment in certain areas such as mental health, primary medical and community health services.

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LTP allocations: Fair Share detail on requirements

The commitments to be delivered through the fair shares funding are as follows:

7

Mental Health The expansion of community mental health services for Children and Young People aged 0-25; funding for

new models of integrated primary and community care for people with SMI from 2021/22 onwards; and

specific elements of developments of the mental health crisis pathways. See 2.27.

Primary Care This funding includes the continuation of funding already available non-recurrently to support Extended

Access and GP Forward View funding streams, (e.g. practice resilience programme), and associated

commitments must be met. Additional funding is also included to support the development of Primary

Care Networks.

Ageing Well Deployment of home-based and bed-based elements of the Urgent Community Response model,

Community Teams, and Enhanced Health in Care Homes.

Cancer Rapid Diagnostic Centres funding in 2019/20 only; Cancer Alliance funding to support screening uptake

delivery of the Faster Diagnosis Standard and timed pathways, implementation of personalised care

interventions, including personalised follow up pathways and Cancer Alliance core teams.

CVD, Stroke and Respiratory Increased prescribing of statins, warfarin and antihypertensive drugs;

Increased rates of cardiac, stroke and pulmonary rehabilitation services; increased thrombolysis rates;

and early detection of heart failure and valve disease.

CYP & Maternity Local Maternity Systems funding; Saving Babies Lives Care Bundle funding from 2021/22; postnatal physio

funding from 2023/24; funding for integrated CYP services from 2023/24.

LD Autism Funding for rollout of community services for adults and children and keyworkers from 2023/24.

Prevention Tobacco addiction - inpatient, outpatient/day case and Smoke Free pregnancy smoking cessation

interventions. Page 57 of 131

LTP allocations: Targeted funding detail on requirements The commitments to be delivered through targeted funding are as follows:

7

Mental Health Includes:

- funding for continuation of previous waves such as mental health liaison or Individual placement support funding; pilots as part of

the clinical review of standards, and other pilots such as rough sleeping.

- funding to be distributed in phases in consultation with regional teams including: funding for testing new models of integrated

primary and community care for adults and older adults with severe mental illness, community based integrated care, rolling out

mental health teams in schools and salary support for IAPT trainees.

Primary Care Digital First Primary Care support funding; the Investment and Impact Fund; and Estates and Technology Transformation Programme.

Ageing Well Targeted funding to accelerator STPs to rollout the Ageing Well models.

Cancer Development and roll out of innovative models of early identification of cancer (starting with lung health checks); funding for the

development of Rapid Diagnostic Centres from 2020/21 onwards; support for further innovations to support early diagnosis.

Technology Revenue funding for Provider Digitisation and Local Health and Care Records.

Cardiovascular Disease,

Stroke and Respiratory

Pilots for improving access to cardiac, stroke and pulmonary rehabilitation services and early detection of heart failure and valve

disease.

Maternity and

Neonates

Continuity of carer for BME and disadvantaged women from 2021/22; funding to support the UNICEF Baby Friendly Initiative; funding

to support the expansion and improvement of neonatal critical care services from 2021/22; funding from 2020/21 for Family

Integrated Care; funding to support the rollout of postnatal physiotherapy and multidisciplinary pelvic health clinics from 2021/22 to

2022/23.

Diabetes Funding to pilot the use of low calorie diets from 2019/20 until 2022/23; funding to support delivery of recommended treatment

targets; funding for multi-disciplinary foot care teams and diabetes inpatient specialist nurses (see 4.31).

Learning Disabilities

and Autism

Funding to pilot and develop community services for adults and children and keyworkers from 2020/21 to 2022/23; piloting of models

to expand Stopping Treatment and Appropriate Medication in Paediatrics (STOMP-STAMP) programmes from 2020/21 to 2023/24;

testing the model for ophthalmology, hearing and dental services to children and young people in residential schools from 2021/22;

funding to reduce the backlog of the Learning Disabilities Mortality Review Programme (LeDeR).

Personalised Care Targeted transformation funding to deliver the NHS Comprehensive Model for Personalised Care from 2019/20–2021/22.

Prevention Alcohol Care Teams from 2020/21 to 2023/24; Tobacco addiction services early implementer sites from 2020/21; targeted support for

weight management service improvements from 2020/21. Page 58 of 131

The London Vision (2019)

The London Vision will focus on areas that only a partnership at London level can address, to make sure:

• Londoners get better outcomes regardless of who they are or where they live • Mental health is treated with the same importance as physical health • Londoners have greater control and choice of their health and care• People receive good joined up care throughout their life regardless of which organisation provides the service

Over the coming months priorities and goals will be set. The work being undertaken across London and will feed into the plans in North Central London.

Emerging Priorities1. Reducing childhood obesity2. Improving mental health of children & young adults3. Reducing inequalities and preventing illness4. Improving air quality5. Improving sexual health6. Reducing the impact of violent crime7. Improving mental health 8. Improving the quality of specialised care9. Making health and care more personalised and joined up at every stage of a Londoner’s life from birth

to end of life 10. Improving the health of homeless people

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Appendices 3: Detail on resident engagement

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NCL Long Term Plan: Engagement Plan

Key inputs, outputs and activities

March – June 2019 June – Aug 2019 Sept-Oct 2019 Nov 2019 –Apr 2020Oct–Feb 2019

Resident engagement phase three

Resident engagement phase two

Resident engagement phase one

Baseline Publish plan

NCL Integrated Care -engagement events

Healthwatch engagement surveys and focus groups

Ongoing engagement through NCL workstream boards

Online stakeholders survey

Borough level targeted engagement with priority groups informed by Healthwatch

NCL STP partners staff briefings on LTP and Change programme

Regular engagement with governance groups (HWB, JCC, JHOSC, CCGs governing bodies)

Engagement on CCGs merger with stakeholder and partners

Borough level engagement with PPGs and citizens panel

Partners and stakeholders staff and residents

engagement on the draft NCL delivery plan

Residents’ representatives, experts by experience and CCG lay members engagement

Refining “I” statements informed by Healthwatch

reports

Draft

plan

Final

plan

Engagement Advisory Board

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1

Islington Clinical Commissioning Group Meeting: Islington Governing Body meeting Date: 11th September 2019

Report Title Islington Walk In Centre

Date of report

23 August 2019

Agenda Item 3.2

Lead Director /

Manager

Clare Henderson

Tel/Email Clare.henderson4@nhs.net

GB Member Sponsor

Clare Henderson

Report Author

Rebecca Kingsnorth / Phil Wrigley

Tel/Email rebeccakingsnorth@nhs.net 020 3688 2936

Name of

Authorising

Finance Lead

Anthony Browne

Summary of Financial Implications

The current Walk in Centre contract is £820k per annum. With the end of the contract, three options are considered for 2020/21 and beyond. Option 1 is to reinvest the proportion of the contract that relates to Islington activity in additional capacity in primary care, and retain a proportion to mitigate any risk of increased attendances at A&E. Option 2 is to retain the full contract value, less the A&E contingency, as a saving. Option 3 is to retain a proportion of the contract value, less the A&E contingency, as a saving and reinvest the remainder in additional capacity in primary care. All options require £8k non-recurrent funding for a navigator post to assist in the signposting and redirection of patients ahead of full closure of the Walk in Centre. Risks associated with each option can be found in the risks summary section. Summary of options, costs and savings

Options Value of current contract

Option cost Net QIPP

Option 1 £820k £361k £459k

Option 2 £820k £36.1k £783.9k

Option 3 £820k £250k £570k

Report Summary

In 2009 Islington PCT commissioned Angel Medical Services to provide a GP Walk In Centre (WIC), based at Ritchie Street Medical Centre. It was previously a mandatory requirement for PCTs to commission GP Walk In Centres, with the intention that they would relieve pressure on both general practice and A&E.

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The expiry of the contract provided the CCG with an opportunity to review the model and its overall alignment with current strategy for urgent and primary care. EMT agreed to develop and implement an agreed model for reinvesting the funding in increased access to primary care. A task and finish group has developed the proposed new model. However, the financial position of NCL CCGs means we are considering financial options again when the WIC closes. Three options are, therefore, presented: Option 1:

Closure of the Walk in Centre when the contract expires

Each Primary Care Network to be funded for additional in-hours capacity and required to deliver consultations which at a minimum equal those provided by the Walk in Centre for Islington residents only;

A proportion of overall investment to go to Islington Federation to be delivered via the i-Hub, to provide additional out of hours appointments;

A risk reserve to be retained to manage any additional A&E attendances resulting from the closure of the Walk in Centre;

A navigator to be placed in the Walk in Centre for three months prior to closure to alert patients to the upcoming change and to support unregistered patients to register with a practice and to encourage registered patients to use their own GP practice and not to attend A&E if they have a primary care problem.

Option 2:

Closure of the Walk in Centre when the contract expires with no re-provision in order to maximise the savings to the CCG;

Retention of a risk reserve as per option 1;

Funding for a navigator as per option 1.

Option 3:

Closure of the Walk in Centre when the contract expires

70% (£250k) of the contract value related to Islington patients (£361k) to be reinvested in primary care with the remainder retained as a saving.

Each Primary Care Network to be funded for additional in-hours capacity and required to deliver consultations which at a minimum equal 70% of those provided by the Walk in Centre for Islington residents only;

A proportion of overall investment to go to Islington Federation to be delivered via the i-Hub, to provide additional out of hours appointments;

Retention of a risk reserve as per option 1;

Funding for a navigator as per option 1.

Recommendation The Governing Body is asked to:

APPROVE the recommendation of the Strategy and Finance Committee that Option 3 is selected; and

NOTE that if Options 2 or 3 are selected there will be a need to liaise with Islington Health Overview and Scrutiny Committee (HOSC) on whether a full public consultation is required following the selection of this option.

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Identified Risks

and Risk

Management

Actions

Willingness of Primary Care Networks to take on additional activity The proportion of the budget reinvested needs to be sufficient for the Primary Care Networks to invest time and resource into developing a robust solution. There is a risk of lack of engagement from the Primary Care Networks for either Option 1 or 3 but this may be increased for option 3. Networks are, however, working together to deliver extended hours in line with the PCN DES, and will be preparing for responsibility for delivery of extended access services from 2021/22. Unintended consequences – diversion of activity to A&E / other WICs There is a risk that some Islington-registered patients who have previously attended the walk in centre will attend A&E or a Walk in Centre in another borough, for which the CCG will be charged. It is proposed that a proportion of the funding available for reinvestment is held as a reserve to accommodate increased costs associated with this. Risk of extension to timeline for closure of the Walk-in Centre if full public consultation is required due to the option selected It will be necessary to liaise with the Health Overview and Scrutiny Committee on whether a full public consultation will be required to implement options 2 or 3.

Conflicts of Interest

Representatives of Islington General Practices will have a conflict of interest in decisions made relating to this paper. Only non-conflicted Governing Body members will vote on this decision.

Resource

Implications

Option 1- financial: savings to be achieved from the overall WIC budget, by removing the out of borough costs of the Walk In Centre. Option 2 – financial: savings to be achieved from full current budget Option 3 – financial: savings to be achieved from a proportion of the current budget

Engagement

Details of engagement process are outlined in this paper and a full report is available on request.

Equality Impact

Analysis

An EQIA was completed at the start of the options development

process. This will be revised for the agreed option.

Report History

and Key

Decisions

EMT – March 2018 and Strategy and Finance – April 2018

Key decision: confirmation that funding would be reinvested in

primary care access with development of options for reinvesting

either in primary care or iHub plus hybrid option

HOSC – 2nd October 2018

Key Decision: Assurance on level of public engagement planned –

The Committee stated that “the process of engagement that the

CCG (was) undertaking to inform the decision making process in

relation to future investment in same day primary care provision

(was) noted”; “approval (was) given to further engagement plans”

EMT – 30th January 2019

Key Decision: agreement that decision to reinvest related only to the

proportion of funding relating to Islington patients

Options Review Meeting – 26th February 2019

Key decision: CCG was asked to develop two further options which

reflect the recent developments in primary and urgent care

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Regular updates to Primary Care Transformation Board in July,

September, November 2018

Islington Strategy and Finance Committee, 29th August 2019.

Next Steps Governance milestones: Update to Health Overview and Scrutiny Committee meeting (September/October) Agreed service specification to Primary Care Committee in Common for information (tbc). Mobilisation: Discussions with Primary Care Networks and invitation to submit a proposal for increased access; Assurance process and approval of proposals by EMT; Communications regarding the closure of the Walk in Centre.

Appendices

Appendix 1 – Service usage information Appendix 2 – Closure of the Walk in Centre

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1 Background In 2009 Islington PCT commissioned Angel Medical Services to provide a GP Walk In Centre, which has been based at Ritchie Street Medical Centre for almost ten years. It was previously a mandatory requirement for PCTs to commission GP Walk In Centres, with the intention that they would relieve pressure on both general practice and A&E. The Walk In Centre has been open to all patients whether or not they reside in Islington or are registered with an Islington GP; the service is staffed by a mix of GPs and nurses and is available from 8.30am every morning until 8pm on weekdays and 9am to 6pm at weekends. The service is commissioned to provide an average of 354 appointments per week. Of those 30% are directly reported as provided to Islington residents and 26% reside in other boroughs. There are 44% of appointments reported in the data as either not registered with a GP or as “GP unknown” 1. Further information on usage of the centre is provided in Appendix 1. The GP Walk in Centre is funded at £820,463 for 2019/20. Since the Walk In Centre was opened there have been a number of other general practice access service developments, which improve access for patients. These are:

GP extended hours, which require practices (and now Primary Care Networks (PCNs) via the PCN DES) to provide an additional period of routine appointments that equates to a minimum of 30 minutes per 1,000 registered patients per week

GP extended access, which provides access to primary care services from 6.30-8pm Monday to Friday and from 8am to 8pm Saturday, Sunday and Bank Holidays. In Islington this provides an additional 580 appointments per week with a projected utilisation rate for 2019/20 of 82% (London target is 85%).

NHS 111, which can already book directly into Extended Access appointments and from 19/20 is beginning to book directly into general practice appointments

Primary care redirection in acute hospital emergency departments which will see patients redirected away from A&E and into general practice.

An Improved Access LIS which incentivised practices to increase the number of core general practice appointments provided, with stretch targets set against the Islington average.

All of these developments are focused on an aligned and coherent model of access to same day primary care – the Extended Access service seeks to provide an equivalent service to core general practice but during an expanded time period. The Walk in Centre, while providing important additional capacity, sits outside of this model and can confuse the offer for patients. The expiry of the 2018-19 contract extension provided the CCG with an opportunity to review how same-day primary care services are provided in Islington, as well as their overall alignment with the CCG’s and national strategies for both urgent and primary care. Islington CCG is committed to increasing access and to providing same day primary care services to the people of Islington.2 EMT agreed to extend the contract with Angel Medical Services until the end of March 2020 to allow sufficient time to:

develop and implement an agreed model for reinvesting the funding in increased access to primary care; and

implement a comprehensive wind down plan for the current Walk In Centre service.

1 For the purposes of this paper we have assumed a 30% share of the unregistered and GP unknowns to be Islington residents – reflecting the percentage of commissioned activity actually recorded as relating to Islington. This increases the Islington element to 44%. 2 NCL General Practice Strategy

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1.1 Process of engagement The Islington CCG primary care and engagement teams, working in collaboration with Healthwatch, implemented a two phase patient and public engagement programme. The feedback obtained from this engagement informed option 1 below. There were two key objectives for the engagement process:

To understand the implications of closure of the WiC model, and whether this disproportionately affected particular groups; and To inform development of the options under consideration for future investment into same day access to primary care

Phase one commenced in June 2018 with the following engagement events:

Presentation at the pan-Islington Patient Group hosted by HealthWatch and delivered by the CCG Assistant Director for Primary Care

Survey of patients using the Walk In Centre (over two days)

Commencement of a series of visits to practice Patient Participation Groups (PPGs)

GP Survey Phase two commenced in November 2018 and continued until the end of January 2019. This phase of the programme included:

Walk In Centre residence for one week with structured questionnaires for unregistered and younger patients

Stakeholder mapping to identify any additional groups

Mystery shopper (testing the process of registering at 10 GP practices across the borough)

GP practice healthcare staff survey

Patient surveys – those who have used the Walk In Centre and those who have not

Continued attendance at Practice Patient Participation Groups

Focus groups for patients with special needs In order to obtain feedback from as many residents as possible, a questionnaire was also sent to practices to be distributed to all members of their Patient Participation Groups. The questionnaire was also published on both the CCG and Healthwatch websites and circulated to other voluntary organisations. In addition to the public engagement, practice staff were provided with feedback from their previous survey and were given the chance to offer further views on the options. An independent report was then commissioned which collated the outputs from all patient and professional engagement since the project began. This is available on request. Summary conclusions are as follows: Both patients and staff said many positive things about the Walk In Centre. Patient satisfaction

is high, getting an appointment is straightforward, the staff are commended, and presenting

problems are generally resolved. The opportunity to ‘walk in’ at any time of day and weekends,

rather than having to book, is popular with younger working adults.

The downsides are lack of access to patient records and background, lack of options for

onward referral, potentially long waiting times, and the location of the service at just one site in

the south of borough. Many patients still do not know about the existence of the Walk In

Centre.

There are implications for closure of the service. These include out-of-hours alternatives,

flexibility of access and booking, options for unregistered and non-local patients, and knock-on

effects for other local health services.

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Overall, there was no clear preference as to how urgent GP services should be offered in the future. Both professionals and the public wanted a service that delivers: Better access (care closer to homes) Equity of service provision More continuity of care Closer management and monitoring Reduced waiting times Integrated with other services Access to patient records and ability to make onward referrals

Some element of same day access to appointments

Better value for money (offering economies of scale)

Regardless of the model chosen ultimately, respondents felt it was important to retain the

opportunity to ‘walk in’ for same-day appointments, maintain equality of access, and promote

and publicise any new service so that everyone knows about it.

1.2 Development of options A stakeholder panel met in February to review the outputs of the engagement process. At this stage any option to reprocure the service in its current form was discounted. A task and finish group then formed to develop the proposed new model, set out as option one in this paper. However, the 2019 financial position of NCL CCGs has brought renewed challenge to the system in terms of how we invest resource which means we are considering again whether to withdraw all funding when the WIC closes. Furthermore, the development of Primary Care Networks (that went live on 1st July 2019) means that both the extended access DES and the separately commissioned extended access service will form part of the PCN contract from 2020 and 2021 respectively thereby bringing a responsibility for PCNs to deliver improved access. This could be further enhanced by a national review of access initiated in 2019. This paper, therefore, reintroduces the option to close the Walk in Centre (Option 2) without reinvestment in a new model in order to realise greater system savings, and introduces a further option (Option 3) that retains a proportion of the contract value associated with Islington, as a saving, reinvesting the remainder.

Options Value of current contract

Option cost Net QIPP

Option 1 £820k £361k £459k

Option 2 £820k £36.1k £783.9k

Option 3 £820k £250k £570k Figure 1 - Summary of options, costs and savings

During 2019/20 there will be a requirement to invest approximately £8k in a non-clinical navigator to support patients on-site prior to the WIC closure, for all options.

2 Options

2.1 Option 1: reinvestment in alternative provision The option to reinvest in alternative provision was developed in line with initial communications with the Health Overview and Scrutiny Committee and subsequent engagement with patients and the public. Following the release of the GP contract guidance, outlining the drive towards delivering extended hours and extended access services at Network level, it was agreed that any alternative service option should be delivered by the Primary Care Networks (PCN).

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Option 1 is therefore:

Closure of the Walk in Centre when the contract expires

Each Network will be funded, on a capitated basis, for additional in-hours capacity and required to deliver consultations which at a minimum equal those provided by the Walk in Centre for Islington residents;

Innovation in consultation type will be encouraged to maximise impact, for example where group consultations could provide a greater number of patient contacts than are provided currently through the Walk in Centre. These could be provided to a specific cohort of patients thus freeing capacity for same day appointments in individual practices;

The proportion of funding related to out of hours appointments will go to the Federation to be delivered via i-Hub;

A risk reserve will be retained to manage any additional A&E attendances resulting from the closure of the Walk in Centre. While there is no evidence that Walk in Centres have had an impact on A&E attendances3, there is a risk that patients used to using the Walk in Centre, particularly those who may be unregistered, may use A&E as an alternative initially;

A navigator will be placed in the Walk in Centre for three months prior to closure to alert patients to the upcoming change and to support unregistered patients to register with a practice.

A six month period has been factored into the project plan from the period following formal sign off for mobilisation of the new model and wind down of the current service. This will commence in September 2019. A key part of this will be working with the Primary Care Networks to establish robust proposals for reprovision of appointments in primary care that are equivalent to, or greater than, those previously provided at the Walk in Centre, and to demonstrate value for money for the investment made. It is proposed that an assurance process is undertaken with proposals assessed for value for money and submitted to EMT for final approval. Provision of the additional appointments can be monitored via the GP Workload Tool, from which practices already submit extracts monthly to support the Improved Access LIS. It is also possible to distinguish these appointments separately from those monitored via the LIS, to prevent double payment. Proportion of funding for reinvestment One principle that we have been working to within this option has been to retain the same level of GP access funding currently being spent on Islington patients using the Walk In Centre, thereby releasing savings with the remainder (as we would no longer offer appointments for out of borough residents). This undertaking was made to the Islington Health Overview and Scrutiny Committee. Arrival at the figure for reinvestment was complex due to incomplete data. Several models have been considered to attribute the data showing GP as ‘unknown’ or unregistered, to calculate a more accurate level of funding associated with Islington. The task and finish group had a preference for assumptions that resulted in a larger figure for investment (and thereby reduced savings). Given the financial position commissioners have proposed to use more cautious assumptions that maximise overall savings to the CCG and indicate that 44% of activity is attributable to Islington patients. In addition, we are advising that a “risk reserve” is established that can mitigate risk of increased attendance at A&E or other Walk in Centres (where Islington CCG may be charged).

3 http://piru.lshtm.ac.uk/assets/files/GP%20patient%20access%20systematic%20review.pdf

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9

This results in the following allocation of funds for reinvestment based on 44% of the contract value (£361k).

Reinvestment in alternative

provision (000)

A&E risk reserve

(10%) (000)

Total (000) (44% of contract

value)

In hours (52.5 hours per week; 67% of total hours) 217.7 24.2 241.9

Out of hours (25.5 hours per week, 33% of total hours)

107.2 11.9 119.1

Sub-total for Option 1 324.9 36.1 361.0

Additional cost of navigator on site prior to closure 8.0 8.0

Total for Option 1 332.9 36.1 369 Figure 2 – allocation of funds – option 1

The “in hours” element of the Walk In Centre budget would provide the following allocation of funds to the Networks:

Network Total network list size Funding allocation (000)

North 96372 £81.6

Central 1 51953 £44.0

Central 2 41778 £35.4

South 67032 £56.7

Total 257135 £217.7

Figure 3 – allocation of funds by network – Option 1

2.2 Option 2: recovery of full cost, no reinvestment The CCG has taken a considered approach to developing options for the Walk in Centre given

the interest of local people and politicians in primary care access. This means we have worked

over a prolonged period to engage with the public and to consider options for retaining

additional appointments within our local primary care system.

However, the financial situation now facing NCL has raised questions about whether we can

afford to retain these additional appointments, particularly given service developments since

the WIC was introduced.

Option 2 is therefore:

Closure of the Walk in Centre when the contract expires with no reprovision in order to

maximise the savings to the CCG;

Retention of a risk reserve as per option 1;

Funding for a navigator as per option 1.

A notable risk of this option is that it goes against the CCG’s undertaking to the Islington Health

Overview Scrutiny Committee (HOSC). For some time, the HOSC has been interested in

primary care access, undertaking a review in 2015/16, and in 2018/19. In order to recognise

the importance Councillors attributed to access, the CCG proposed that within the closure of

the WIC we would maintain investment in primary care access. The CCG considers this to be

ensuring that the appointments currently used by Islington patients will be re-provided

elsewhere in the system (hence option 1).

At an early stage we discussed our plans with the HOSC chair and agreed that this would form

engagement rather than a full public consultation. Commissioners have continued to report

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10

back to the Committee during 2018 and 2019. If this option were selected it would be

necessary to liaise with Islington Health Overview and Scrutiny Committee on whether a full

public consultation is required.

If this were required, the formal consultation would require investment which the Islington

senior patient engagement manager estimates at around £28,000. The process for formal

consultation would take approximately 8 months, allowing for 3 months of public engagement,

time to write up the evaluation report, time for review and feedback prior to taking through

standard governance channels. This would result in a requirement to extend the current Walk-

in Centre contract further as we would not be able to plan for closure of the Walk-in Centre until

the consultation were complete. In addition, NHS England may require the proposal to be

reviewed by the Clinical Senate, which may increase the overall timeframe roughly to around

12 months.

2.3 Option 3: reinvestment of a proportion of funds, retention of some savings

Option 3 is:

Closure of the Walk in Centre when the contract expires

70% (£250k) of the contract value related to Islington patients (£361k) to be reinvested

in primary care with the remainder retained as a saving.

Each Primary Care Network to be funded for additional in-hours capacity and required

to deliver consultations which at a minimum equal 70% of those provided by the Walk in

Centre for Islington residents only. There is scope through innovation for the current

level of Walk in Centre appointments to be replaced with new forms of appointment

delivered at PCN level, at lower unit cost – this would need to be explored with the

PCNs;

A proportion of overall investment to go to Islington Federation to be delivered via the i-

Hub, to provide additional out of hours appointments;

Retention of a risk reserve as per option 1;

Funding for a navigator as per option 1.

This option provides reinvestment of the majority of resource currently allocated to Islington

patients. If this option were selected it would be necessary to liaise with Islington Health

Overview and Scrutiny Committee on whether a full public consultation is required.

This results in the following allocation of funds for reinvestment based on reinvesting 70% of the contract value related to Islington patients (i.e. 70% of £361k).

Reinvestment in alternative

provision (000)

A&E risk

reserve (10%) (000)

Total (44% of contract value, less

30% for savings)

In hours (52.5 hours per week; 67% of total hours)

150.8 16.8 167.5

Out of hours (25.5 hours per week, 33% of total hours)

74.3 8.3 82.5

Sub-total for Option 3 225.0 25.0 250.0

Additional cost of navigator on site prior to closure

8.0 8.0

Total for Option 3 233.0 25.0 258 Figure 4 – allocation of funds option 3

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The “in hours” element of the Walk In Centre budget would provide the following allocation of funds to the Networks:

Network Total network list size

Funding allocation (000)

North 96372 £56.5

Central 1 51953 £30.5

Central 2 41778 £24.5

South 67032 £39.3

Total 257135 £150.8

Figure 5 – allocation of funds by network – Option 3

Networks are currently working together on delivery of extended hours as described in the PCN

DES, and will be preparing for collective responsibility for delivery of extended access services

from 2021/22.

2.4 Summary The following table sets out each option against key areas for consideration:

Option 1 – close and invest in additional appointments in PCNs and iHub

Option 2 – close and retain funding towards financial gap

Option 3 – close and invest a proportion of funding in additional appointments in PCNs and iHub

National targets – does this option contribute to our national targets?

Yes – improved access No Yes – improved access

Discretionary – do we have to provide this service?

No No No

Affordability – is there an identified funding source and is the proposal cost effective?

Yes – funding identified and scope for increased value for money

This would deliver savings through transactional QIPP

Yes – funding identified, scope for increased value for money, and would deliver savings through transactional QIPP

Patient Voice – does this option respond to patient engagement?

Yes No Partially

Wider stakeholders – will we have community support for this option?

Yes No Not known

3 Conclusion Islington patients and patients from out of the borough have benefitted from a Walk in Centre for the past 10 years. However, it has been recognised that the current model duplicates other GP access services and there is a need to focus resources on Islington patients. The development of alternative options has involved engagement with local clinicians, patients and wider stakeholders including the London Borough of Islington Health Overview Scrutiny Committee.

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12

The task and finish group has developed Option 1 set out in this paper. However, because of the financial situation facing Islington CCG it is prudent at this point to test whether we could move to an Option 2 where the WIC is closed with no onward investment, or Option 3 where a proportion of current Islington-related investment for the WIC is retained for savings, with the majority reinvested in primary care. Although financially prudent, Option 2 would put the CCG into a challenging position with patients and wider stakeholders as we have not held a formal public consultation on closure. Instead we agreed that we would carry out public engagement on the change of service. Appendix 1 sets out this engagement to date. This risk remains for Option 3, and we would need to liaise with the Health Overview and Scrutiny Committee on whether a full public consultation is required. It is recommended that Option 3 is approved, given the extent to which this balances

commitments made to the HOSC and to patient engagement, with the need to ensure a

sustainable financial position for the CCG.

A national review of access is planned during 2019/20 which may inform the further

development beyond 2020/21.

The Governing Body is asked to:

APPROVE the recommendation of the Strategy and Finance Committee that Option 3 is

selected; and

NOTE that if Options 2 or 3 are selected there will be a need to liaise with Islington HOSC

on whether a full public consultation is required following the selection of this option.

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Appendix 1: Walk in Centre usage

Data collected by the Walk In Centre in 2017/18 shows that GP is recorded as ‘unknown’ for

the majority of consultations with the service. This can mean that these people did not opt to

give this information, were genuinely not registered anywhere with a GP or were not directly

asked by staff whether they were registered with a GP. This is partly due to a lack of

consistency in the way on which the service records data. In the past it has not been possible

to determine accurately the proportion of consultations taking place with people who are not

registered with a GP at all, however the Engagement Report below seeks to address this data

gap to some degree.

The second largest group of patients to use the service are those registered with the host

practice (Ritchie Street practice). A total of 26% of the overall activity in 2017/18 was from

Ritchie Street practice.

Figure 6 – appointments per practice4

In the graph above it should be noted that “Unregistered Patients” also includes registered

patients who have not provided information about their own GP. It should also be stressed that

25% of the activity is provided outside the Walk In Centre contract which was negotiated by the

service to allow for extra Ritchie Street patients to be seen in the Walk In Centre – excluding

this percentage reduces the number of Ritchie Street registered patients seen in the Walk In

Centre to 4364 which is still higher than any other practice.

4 Please note that this table only includes consultations with patients from Islington practices (where GP is recorded as

‘unknown’ this may include patients from outside Islington).

7,240

5,818

769 512 333 332 244 228 206 182 150 149 148 147 122 114 110 107 87 860

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

WIC 2017/18 Home GP practice

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14

Figure 7 – postcode of patients attending the walk in centre

Figure 7 above shows that a significant proportion of people who have used the Walk In Centre

live in the N1 postcode.

The following postcodes shown on the graph above are outside Islington: E17 (Walthamstow),

NW5 (Kentish Town), E1 (Mile End, Stepney and White Chapel), E2 (Bethnal green and

Shoreditch), E8 (Hackney and Dalston) and N16 (Stamford Hill and Stoke Newington).

The data suggests that the majority of Islington practices have very few patients that use the

Walk In Centre, though some practices that are local to the service appear to use it more

frequently than others. Following interviews with Patient Participation Groups (PPG) across the

borough it is apparent that the current Walk In Centre is used mainly by patients who live in the

near vicinity of the centre and, in spite of the service being in place for almost ten years, most

people interviewed at PPGs were unaware of its existence.

The feedback from patient engagement suggests that people are using the service because

they are unable to get a GP appointment at their own practice, or they think they won’t be able

to get an appointment, or they don’t want to wait for one.

It is not uncommon for host practices to be the biggest user of a borough wide service and

attempts were made to balance this when the service was set up. However, the disparity in

access to this service for all Islington residents is quite stark, suggesting an inequality in access

for all Islington residents. As noted above, Angel Medical Services do provide over and above

the commissioned number of appointments in order to accommodate additional activity from

Ritchie Street Practice patients, so a proportion of the appointments shown for Ritchie Street

patients are provided at no additional cost to the commissioner.

8,002

1,965

1,3151,044

721439 401 364 345 258 186 177 122 109 103 82 82 82 80 75

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

WIC 2017/18 Top 20 patient postcodes

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15

Figure 8 – Age and gender of patients attending the Walk-in Centre compared to the general population

– please note that these data relate to the number of consultations, not the number of patients. It is

not possible to disaggregate the Islington patients from these figures, therefore this chart includes

patients from out of area.

Younger people are the predominant users of the Walk In Centre, with people between 20 and

29 attending at higher rates than other age groups, which is consistent with the findings of the

Monitor Evaluation of Walk In Centres nationally in 20145. This supports the assumption that

the Walk In Centre is predominantly used by patients of working age, including those from other

boroughs who are visiting or are working in Islington. Women tend to use the centre slightly

more than men.

5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/283778/WalkInCentreFinalReportFeb14.pdf

-40%

-30%

-20%

-10%

0%

10%

20%

30%

40%

50%0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Walk In Centre Age vs ICCG Age, Q1 - Q3 2017/18

ICCG - Femal ICCG - Male WIC - Female WIC - Male

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16

Figure 9 – ethnic origin of patients attending the Walk in Centre

The service does not consistently record the ethnic origins of patients and it has been difficult to

assess whether a particular group of people prefer to access same day primary care services in

this way.

What conditions are treated at the walk-in-centre?

Information about the conditions treated at the walk in centre is not READ6 coded by the Walk

In Centre; a free text section is completed by the receptionist which allows no consistency for

analysis. However, having reviewed the data, the list below reflects the main types of

conditions for which patients are seeking a same day appointment. All of these conditions could

be managed in primary care – either in general practice or at a pharmacy – alternative services

are shown below for each, depending on severity of the condition:

Focus of consultation Alternative service available

Constipation/Diarrhoea Pharmacy, GP practice, self care

Pain Pharmacy, GP practice, self care

Minor Ear Conditions Pharmacy, GP practice, self care

Cough/chest infection/sinusitis/sore throat

Pharmacy, GP practice, self care

Viral illness Pharmacy, self care, GP practice

Rash Pharmacy, GP practice, self care

Urinary tract infection GP practice, Urgent Treatment Centre (UTC), pharmacy

Dysmenorrhoea Pharmacy, GP practice, self care

Back Pain Pharmacy, GP practice, self care

6 READ coding is the standard clinical terminology system used in General Practice in the United Kingdom.

AMS 2017/18 Top 10 Ethnic Origins (excludes "ethnicity not stated")

British or mixed British

White British

Other White background

Other

African

Irish

Chinese

Other Mixed background

Indian or British Indian

Black British

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17

Haemorrhoids Pharmacy, GP practice, self care

Dressing and wound management GP practice, UTC

Low mood/anxiety/depression Pharmacy, GP practice, self care

Prescribing

It is difficult to provide an accurate picture of the prescribing at the Walk In Centre since

prescribing coding is combined with Ritchie Street Medical Centre. However a small sample of

prescribing over the last two years has been coded separately and the top 20 most prescribed

items are outlined below showing the conditions for which they are prescribed and where they

are also available over the counter. It is clear from this chart that half of the conditions could

have been managed by a community pharmacist.

Drug Name Information on Indication

Available Over

The Counter

(OTC) from

Community

Pharmacy

Naproxen_Tab 500mg

Pain and inflammation in a range of

conditions

No

(NB: lower strength

250mg tablets are

available for period

pain)

Amoxicillin_Cap 500mg Antibiotic No

Nitrofurantoin_Cap 100mg

M/R Antibiotic No

Fluclox Sod_Cap 500mg Antibiotic No

Salbutamol_Inha 100mcg

(200 D) CFF Inhaler for asthma or COPD No

Phenoxymethylpenicillin

Pot_Tab 250mg Antibiotic No

Clarithromycin_Tab 500mg Antibiotic No

Ibuprofen_Oral Susp

100mg/5ml S/F

Reduce pain and inflammation in a

range of conditions and reduce fever Yes

Loratadine_Tab 10mg

Antihistamine - to relieve symptoms of

allergy (includes hayfever,

conjunctivitis, eczema, hives, insect

bites and stings and some food

allergies) Yes

Prednisolone_Tab 5mg

Corticosteroid - used as an anti-

inflammatory used to treat a range of

conditions e.g allergy and

anaphylaxis, asthma and COPD No

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Co-Codamol_Tab

30mg/500mg

Moderate to severe pain (NB:

combination of two painkillers:

codeine and paracetamol) No

Chloramphen_Eye Dps 0.5% Antibiotic to treat eye infections such

as conjunctivitis Yes

Phenoxymethylpenicillin_Soln

125mg/5ml Antibiotic No

Paracet_Tab 500mg Reduce pain and inflammation in a

range of conditions and reduce fever Yes

Levonorgest_Tab 1.5mg Emergency Contraception Yes

Paracet_Oral Soln Paed

120mg/5ml S/F

Reduce pain and inflammation in a

range of conditions and reduce fever

Clotrimazole_Pess

500mg/Crm 2%

Antifungal treatment used to treat

vaginal thrush Yes

Fexofenadine HCl_Tab

180mg

Antihistamine - to relieve symptoms of

allergy (includes hayfever,

conjunctivitis, eczema, hives, insect

bites and stings and some food

allergies) No

Ibuprofen_Tab 400mg Reduce pain and inflammation in a

range of conditions and reduce fever Yes

Sodium Fusidate_Oint 2% Topical Antibiotic No

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19

Appendix 2: Closure of Walk In Centre The CCG will work closely with Ritchie Street Medical Practice to ensure a smooth transition when the Walk In Centre closes and to support them to manage patients’ expectations and any potential increase in their practice activity. Promotional material will be made available at Ritchie Street for all local pharmacies, GP practices, extended access hubs as well as self-care promotional material (it should be noted that a number of conditions seen at the Walk-in Centre could be seen in community pharmacies). Support will be ramped up in the last three months prior to the closure of the Walk In Centre to ensure that all regular users of the service are aware of alternative routes of accessing urgent care. It is proposed that for three months from January until March 2020, a primary care navigator will be on site at Ritchie Street to liaise with patients who currently use the Walk In Centre, inform them of the imminent closure of the service and to promote other ways of accessing urgent, non-acute care, with a focus on 111 and the local extended access service. The Navigator will also support Islington patients, who are unregistered with a GP, to register at local practices and will provide advice to out of borough patients on how to register with a GP in their area. The cost of this post is estimated at £8,0007 A communications plan is currently in development with the CCG senior communication lead, which will include communications to the public, local practices, neighbouring CCGs and local Trusts. We have examples from other areas to indicate the materials likely to be required. The communication team will make use of existing and free channels; therefore, costs are solely for printed materials and paid-for advertising.

7 WTE band 4 (mid-point with Inner London weighting): £26,219 plus 20% on costs £5,244 (3 months only)

Page 80 of 131

Islington Clinical Commissioning Group Governing Body Meeting 11 September 2019

Report Title Islington CCG 2019/20 Month 4 Finance Report

Date of report

28th May 2019

Agenda Item

4.1

Lead Director /

Manager

Anthony Browne Director of Finance

Tel/Email 020 3688 1394 Anthony.Browne@nhs.net

GB Member Sponsor

Simon Goodwin Chief Finance Officer

Report Author

Anthony Browne Director of Finance

Tel/Email 020 3688 1394 Anthony.Browne@nhs.net

Name of

Authorising

Finance Lead

Simon Goodwin CFO

Summary of Financial Implications

This paper sets out the financial position reported to NHS England for Islington CCG at Month 4 2019/20.

Report Summary

At Month 4 the CCG is reporting a deficit of £0.4m year to date position and forecasting to plan at year end. The year to date deficit is driven by GP @ Hand costs, the FOT for GP @ Hand is £1.03m and the CCG has assumed that these costs will be met in year although it has been flagged as a risk within NHSE returns. It should be noted that the position is based on April to June activity data with an estimate for July. The CCG faces the following risk in meeting its control total from a number of different areas:

Contracts have been set with cap/collar arrangements (RF & NMUH), block (UCLH) and straight PBr (Whitt) which exposes the CCG to varying degrees of activity and price risk during the year. The UCLH and RF contracts are not yet signed.

Marked increase in out of sector Acute activity and cost year on year

QIPP achievement in 2019/20 is vital given the limited reserves and ability to mitigate based on final operating plan returns

QIPP has been agreed both within and outside of contract depending on contract form

Controlling cost and volume growth in areas such as Continuing Care & Prescribing

In order to deliver the balanced forecast CCG are required to deliver net QIPP efficiencies of £12.9m (3.1%). The CCG has developed a £14m gross QIPP programme in 2019/20 and set aside incremental investment of £1m to support delivery.

Page 81 of 131

The Governing Body is asked to note the risks above the reported position detailed within the report. The CCG has identified £6.4m of risks and £2.7m of mitigations leaving a net risk of £3.7m. Risks are largely due to increases acute activity risk, potential for slippage in QIPP delivery, GP @ Hand costs, and increases in Primary Care Prescribing charges relating to No Cheaper Stock (NCSO) and Short Stock Drug (SSD).

Recommendation The Governing Board is asked to NOTE the financial position at Month 4.

Identified Risks

and Risk

Management

Actions

This paper includes an assessment of financial risks.

Conflicts of Interest

Not Applicable

Resource

Implications

There are no direct resource implications for this paper, as it is not a project

proposal for additional internal resourcing, nor is it assuming additional external

resourcing

Engagement

Not Applicable

Equality Impact

Analysis

No Equality Impact Assessment is planned or has been undertaken for the finance report itself, though individual QIPP schemes undergo the assessment.

Report History

and Key

Decisions

Not Applicable

Next Steps Updates to be provided when available

Appendices

None

Page 82 of 131

Finance ReportMonth 4 2019/20

Page 83 of 131

2

The CCG has submitted a balanced Plan for 2019/20

Executive Summary

Summary position

o Balanced Position – The CCG is reporting a balanced

year to date position and is forecasting to plan at year

end. Information received from some Acute Providers

has been adjusted but there are still cost pressures

reported here that are being offset by non recurrent

funds held currently within the Acute Demand Reserve.

o Acute – Details of all Acute contracts are shown later in

the report.

o Non Acute – Includes Mental Health (NHS and Local

Authority), Community (includes Better Care Fund),

Continuing Healthcare (Adults and Children) and

Primary Care (includes Delegated Commissioning and

Prescribing and NHS 111). The surplus shown here

relates to underspends in Continuing Healthcare and

Community Services.

o Programme Corporate Costs – this includes STP

Funding, London Healthy Living Partnerships, QIPP

Team, Nursing and Quality, Safeguarding (Adults and

Children), Planned Care, Care Closer to Home and

Hosted allocations from NHSE that we have yet to

receive the NCL breakdown.

o Corporate & Running Costs – this includes support

from NELCSU, CCG staff and estates and the costs for

NCL Senior Management Team.

Table 1 - Summary Financial Position

Summary financial position (£m)

YTD Full Year

Bud Actual Var Bud FOT Var

Revenue Resource Limit 142.4 142.4 - 433.5 433.5 -

Acute 68.1 69.2 1.1 205.2 208.2 3.0

Non-Acute 66.3 66.4 0.1 202.1 201.3 (0.8)

Programme Corporate

Costs1.8 1.9 0.0 7.9 8.0 0.1

Corporate & running costs 1.7 1.6 (0.1) 5.1 5.1 0.0

Total Operational 138.0 139.1 1.1 420.2 422.6 2.3

Contingency - - - - - -

Acute Demand Reserve (0.0) (0.7) (0.7) (0.0) (2.4) (2.3)

Total Non Operational (0.0) (0.7) (0.7) (0.0) (2.4) (2.3)

Total Expenditure 138.0 138.4 0.4 420.2 420.2 (0.0)

Surplus / (Deficit) 4.4 4.0 (0.4) 13.3 13.3 0.0

Prior month - (0.0) (0.0) - (0.0) (0.0)

Page 84 of 131

Acute Contracts

o Whittington – For 2019/20 reporting

the Community element of the

Whittington contract is shown within

Non Acute. This contract is a PbR

contract and the main pressures are

within Non Elective

o UCLH is a Block Contract in 2019/20

apart from High Cost Drugs and

Devices that will be charged on use.

o In Sector: Other contracts are PbR for

In Sector although the small contract

with NMUH is a Cap and Collar

construct. Cost pressures across

Moorfields, NMUH and RNOH have

been challenged

o Other Out of Sector – the outstanding

issues here relate to Homerton. This

contract of £5m has yet to be agreed

due to a dispute over baseline values.

o This pressure is offset by Non recurrent

measures as there is not a material

Acute Demand Reserve in 19/20.3

Acute FOT is a deficit at month 4 of £3.0m that is offset by Non

Recurrent funding held within the Acute Demand Reserve

Acute Performance

Table 2 - Acute Performance Month 4 2019/20

Acute performance (£m)

Trust / Service

YTD Full Year

Bud Actual Var Bud FOT Var Var %

£m £m £m £m £m £m %

Whittington 23.3 24.7 1.4 70.1 72.7 2.6 4%

UCLH 25.7 25.7 (0.0) 77.5 77.4 (0.0) 0%

Royal Free 4.4 4.1 (0.3) 13.3 13.3 (0.0) 0%

Moorfields 1.7 1.8 0.1 5.0 5.4 0.4 7%

North Mid 0.3 0.4 0.1 0.9 1.1 0.2 20%

RNOH 0.2 0.3 0.1 0.6 0.9 0.3 45%

GOSH 0.2 0.2 (0.0) 0.6 0.6 - 0%

Total In Sector 55.8 57.2 1.4 167.9 171.3 3.4 2%

Barts 2.5 2.5 0.1 7.5 7.7 0.2 2%

Other Out of Sector 3.9 4.0 0.1 11.6 12.2 0.6 5%

Non Contracted Activity 1.2 0.9 (0.3) 3.6 3.1 (0.5) 15%

SLA Exclusions 0.6 0.5 (0.1) 1.7 1.4 (0.3) 17%

Acute Planned Care 1.0 0.9 (0.1) 3.1 2.9 (0.3) 8%

London Ambulance

Service3.4 3.4 - 10.4 10.4 (0.0) 0%

Other Acute 12.6 12.3 (0.3) 37.9 37.6 (0.3) 1%

Total Acute 68.4 69.4 1.1 205.9 208.9 3.0 1%

Prior month 50.5 52.1 1.6 205.0 206.7 1.6 0%

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QIPP Summary

Islington QIPP plan is £12.98m for 2019/20

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Table 3 - QIPP Programme

Islington QIPP Schemes - 2019-20

Programme Area

Net QIPP - YTD Net QIPP - Full Year

Plan Actual Variance Delivery

%Varianc

e Plan Actual Variance Delivery %Variance

Acute

Care Closer to Home 0.12 0.10 -0.02 84% -16% 0.48 0.48 0.00 100% 0%

Other Acute 0.12 0.12 0.00 100% 0% 0.82 0.82 0.00 100% 0%

Planned Care 0.55 0.61 0.06 112% 12% 4.31 4.31 0.00 100% 0%

Primary Care / Prescribing 0.03 0.01 -0.03 21% -79% 0.29 0.08 -0.21 26% -74%

Urgent and Emergency Care 0.75 0.67 -0.08 90% -10% 4.04 4.04 0.00 100% 0%

Acute Total 1.57 1.51 -0.06 96% -4% 9.93 9.72 -0.21 98% -2%

Non-Acute

Community 0.16 0.16 0.00 100% 0% 0.48 0.48 0.00 100% 0%

Continuing Healthcare 0.05 0.05 0.00 100% 0% 0.38 0.38 0.00 100% 0%

Mental Health 0.22 0.14 -0.08 62% -38% 0.95 0.61 -0.34 65% -35%

Primary Care / Prescribing 0.03 0.00 -0.03 0% -100% 1.24 1.09 -0.15 88% -12%

Non-Acute Total 0.46 0.35 -0.11 75% -25% 3.05 2.56 -0.49 84% -16%

Grand Total 2.03 1.86 -0.17 91% -9% 12.98 12.28 -0.70 95% -5%

Progress Update:

• For 2019-20, Islington CCG’s QIPP portfolio aims to deliver net savings of £12.98m with associated investment of £1.024m. The

Year to Date position for M4 shows delivery of 91% with a forecasted achievement of 95% by the end of the year.

• Haringey and Islington CCG’s have set up ‘Star Chambers’ that am to identify potential mitigations early in the financial year to

offset any slippage that could be experienced in future periods, as there are risks of £2.56m within the portfolio.

Key movements:

• CHC – YTD NCL CHC programme increased by £22k and FOT increases by £112k

• Primary Care Prescribing – YTD for Technology enabled medicines optimisation reduced by £16k and FOT downgraded to £75k

• Mental Health – YTD and FOT reduced to £0 for the recommissioning of Hanley Gardens

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Non-acute performance

• CIFT Block Contract has a number of investments in

MH lounge, Neuro Development Disorders, Perinatal,

Peer Coaching and ILAT

• Minor pressures on other areas within Mental Health

but no significant pressures within Section 75

agreements based on quarter one returns.

• BCF Investment is £18m overall but some BCF spend

is within other contracts and held within block

agreements.

• Minor underspend on Community cost and volume

contracts

• Update on database for Continuing Healthcare

showed a reduction in forecast for Funded Nursing

Care.

• Prescribing figures are shown as to plan as we have

not received the forecast for 19/20. This is due in

month 5.

• Primary care Delegated includes the year to date

pressure for GP @ Hand.

Non-acute and Corporate costs

Non- Acute services have reported £0.8m surplus against plan which assists in

offsetting the overspend in Acute

Table 5 - Non Acute & Corporate Performance

Non Acute & Corporate (£m)

Trust / Service

YTD Full Year

Bud Actual Var Bud FOT Var

£m £m £m £m £m £m

Non-acute

Camden & Islington MH NHS

FT13.2 13.2 (0.0) 39.6 39.6 -

MH Adult & CAMHS & LD 4.6 4.8 0.1 13.9 13.9 0.0

BCF Investment 4.4 4.4 - 13.3 13.3 -

Whittington Health Community 12.5 12.5 (0.0) 37.5 37.5 -

Community Health Services 2.0 1.9 (0.1) 6.9 6.7 (0.2)

Adult Continuing Healthcare 5.1 4.9 (0.2) 15.6 15.2 (0.4)

Primary Care 1.9 1.9 (0.0) 5.7 5.7 (0.0)

Prescribing 8.6 8.6 (0.1) 26.3 26.2 (0.0)

Primary Care Delegated

Commissioning12.4 12.7 0.3 38.8 38.8 -

Other incl EOLC & Sexual

Health0.7 0.6 (0.0) 2.0 1.9 (0.1)

NHS 111 & Out of Hours 0.8 0.8 (0.0) 2.4 2.4 -

66.3 66.4 0.1 202.1 201.3 (0.8)

Corporate & Estates

Other Programme Costs 1.8 1.9 0.0 7.9 8.0 0.1

Corporate & Running Costs 1.7 1.6 (0.1) 5.1 5.1 0.0

3.5 3.5 (0.0) 13.0 13.1 0.1

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Risk & Mitigations

Additional Risk has been added due to costs relating to GP at Hand services

6

o This is the basis of the ICCG Operating Plan submission to NHSE.

o The Acute Risk is a combination of calculated QIPP Risk and Contract Risk, the former being an estimate of the worst case position on the basis of the acute contract form at each Trust.

o Mental Health Risk relates to potential QIPP slippage which is to be reviewed.

o Primary Care Services relates to risk on Prescribing charges (NCSO and SSD).

o Primary Care Delegated risk relates to GP at Hand costs presented by Hammersmith & Fulham CCGs at month 2. The CCG is working with NHSE to understand the 2019/20 impact and have identified as risk until fully confirmed.

o Community risk relates to a notified increase in BCF spend of £0.9m. Central funding has been flagged for this but has yet to be confirmed.

o Mitigations previously shown against Other Programme have been moved to more appropriate areas after the initial Star Chambers.

Table 4 - Risk & Mitigations

Risk and mitigations (£m)

Emergent risk

Current

Month

Last

Month Change

Mitigatio

ns

FOT

Acute Services (2.8) (3.0) (0.2) -

Mental Health (0.5) (0.3) 0.3 -

Community Health (0.9) - 0.9 1.9

Continuing Care - - - 0.8

Primary Care Services (1.2) (1.2) - -

PC Co-Commissioning (1.0) (1.0) 0.1 -

Unidentified QIPP - - - -

Other Programme - - - -

Total (6.4) (5.4) 1.0 2.7

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CCG M04 Narrative supporting Non-ISFE submissions

Barnet At M4 the CCG is on plan and is forecasting to deliver its planned deficit. No significant variances to report. The reported risks are as per the Op Plan submission, with the addition of the GP at Hand impact. This is included in the YTD position but not in FOT, as per NHS England guidance; continues to be shown as a risk/cost pressure.

Camden The CCG is reporting to a Planned Deficit of £4.8m, including a forecast overspend of £1.9m on GP Delegated Commissioning. Acute services continue to report forecast overspends, which is primarily due to the RFH, Imperial and other out of sector providers. In addition the CCG have identified gross risks of £7.6m, of which £4.1m has been mitigated. Net risks are £3.5m, an increase of £2.4m from the month 3 position, including GP @ Hand.

Enfield As at 2019/20 month 4, Enfield CCG is reporting as per plan. Risk is £8.24m, including GP @ Hand.

Haringey The 2019/20 financial plan for the CCG is a £14.1m deficit at the year-end. As at month 4, the CCG is reporting to plan for the year-end with a YTD over-spend of £0.2m.The CCG has assessed the risk to its position as a net £5.5m. This largely relates to potential acute over performance, delivery of QIPP/STP intervention and unfunded GP @ Hand cost pressures. The CCG is working to identify additional efficiencies to mitigate acute over-performance and under delivery of existing QIPP schemes.

Islington The CCG has reported a year to date pressure of £0.4, relating mainly to GP @ Hand costs. The forecasted pressure for this is included in Risks but is not in the reported position. Other risks include the pressure relating to Better Care Funding. The CCG is still forecasting a break-even position for 2019/20. Challenges continue to be raised against two local Acute Providers, with regard to the quality of data submitted for monthly reporting. The overspend reported against Acute services has been offset by non recurrent provisions and work beginning on additional transactional QIPP.

NCL CCG Summary Financial Position -

Month 04 19/20

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Islington Clinical Commissioning Group Meeting: Governing Body Date: 11 September 2019 Report Title Performance Report Date of

report 21 August 2019

Agenda Item 4.2

Lead Director /

Manager

Elizabeth Ogunoye, Director of Acute Commissioning and Performance Improvement, Haringey and Islington CCGs

Tel/Email elizabeth.ogunoye2@nhs.net

GB Member Sponsor

Not Applicable

Report Author

Andrew Broddle, Head of Performance and Planning, Islington CCG

Tel/Email a.broddle@nhs.net

Name of

Authorising

Finance Lead

Not Applicable Summary of Financial Implications

Not Applicable

Report Summary

The Acute Services Performance and Quality Report to the JCC, the Mental Health Performance and Quality Report and the Community Services Transformation Work – Update provide the overviews of the performance of Islington Clinical Commissioning Group (CCG) and its main providers in relation to the NHS national constitutional standards and key performance indicators. As the Governing Body will be aware (due to reporting timetable differences) the performance report contain different months’ activity. This is stated within the relevant sections of the reports. This report highlights specific areas of performance to note. Further additional information on acute and community service performance is contained in the reports listed below:

NCL August 2019 Acute Services Performance and Quality Report- which can be found here.

NCL August 2019 Mental Health Performance and Quality Report- which can be found here.

Whittington Health NHS Community Services Dashboard (June 2019- which can be found here

Community Services Transformation Work July 2019 Update

Adult CSIG 30 July 2019- which can be found here

CYP CSIG 30 July 2019- which can be found here

CAMHS Waiting time update June 2019- which can be found here

Recommendation The Governing Body is asked to NOTE the contents of this report and appendices.

Identified Risks

and Risk

Not Applicable

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Management

Actions

Conflicts of Interest

Not Applicable

Resource

Implications

Not Applicable

Engagement Not Applicable

Equality Impact

Analysis

Not Applicable

Report History

and Key

Decisions

Not Applicable

Next Steps Not Applicable

Appendices Not Applicable

1. Overview The Acute Services Performance and Quality Report produced by North East London Commissioning Support Unit (NEL CSU) details performance against constitution targets. The Mental Health Performance and Quality Report produced by NEL CSU details performance against the mental health standards and targets. The Whittington Health NHS Trust Quality and Performance Dashboard details performance against the community targets and the Community Services Transformation Work – Update reports on the improvement work, overseen by the Community Services Improvement Group (CSIG), with respect to adult and children and young people community based services provided by Whittington Health. It should be noted that sections of the report contain different months’ activity, due to the reporting timetable. This is stated as clearly as possible within the report and near-time local intelligence is included, where relevant. 2. Performance 2.1 A&E The full report showing performance of the A&E four hour waiting standard for July 2019 for each provider is reported in August NCL Acute Services Performance and Quality Report and is available as a link within the September Governing Body papers for information. In summary, overall performance for July 2019 at the Whittington was 84.8% against an improvement trajectory of 92%. Performance decreased in July from June 2019 (when overall performance was 90.1%). This was related to high attendances (9,454), and staffing issues. The Islington A&E Delivery Board continues to monitor the progress of the delivery of the A&E standard at the Whittington. At the July meeting, Islington’s A&E Delivery Board discussed the progress of the improvement programme for 2019/20 and the current challenges for the system. The improvement programme is a system wide approach to managing the A&E pressures and improving and standardising processes for patient assessment, admission and discharge across 7 days to achieve the 4-hour operational standard. The delivery of the 2019/20 Improvement Programme is managed through three distinct work streams focusing on specific priorities for the system: Inflow, Through flow and Outflow.

The Inflow work stream focuses on managing demand in the community and reducing avoidable A&E attendances and hospital admissions.

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The Through flow work stream focuses on improving internal Whittington Health processes that enable staff to deliver the highest quality of care in a timely way and ensure a positive patient experience.

The Outflow work stream focuses on timely and effective transfer and discharge of patients from both the Emergency Department and wards into community settings.

2.2 Delayed Transfers of Care (DToC) Performance Delayed transfers of care are where patients in acute hospitals are medically fit for discharge, but are unable to be discharged. This can be due to delays in social care or when care in a more appropriate healthcare setting is not available. These delays create a poor patient experience and impact on the availability of acute beds for more acutely ill patients. Figure 1, shows the delayed transfers of care at Whittington Health. Provisional data indicates that during July 2019 performance was above the 3.3% target, with an average percentage of bed base of 4.6%. The daily DTOC position in July ranged between 2.5% and 7.2% against the bed base. The DTOC rate at the Whittington increased in July due to an increase in delayed transfers of care for patients who require complex care including neuro rehabilitation, dementia nursing placements and continuing health care. Some of the main causes identified as contributing to the delays included staffing challenges within Haringey’s social care team and the shortage of specialist nursing placements available in both boroughs. Islington CCG is working closely with Whittington Health in reducing avoidable delays in transfer of care through daily discussions of the medically optimised patients and weekly senior reviews of complex DToC cases that require additional support. Islington has a fully staffed social care team based at Whittington Health that supports timely and effective discharge of patients and Haringey have also committed additional resources for one social care worker to be based on site. The aim is to improve the flow of information and reduce delays in assessments of patients who are medically optimised. Figure 1: Delayed Transfers of Care Whittington Health.

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2.3 Continuing Health Care (CHC)

2.3.1 Continuing Healthcare (CHC) in the acute setting The target for the percentage of decision support tool (DST) assessments carried out in an acute setting is 15%. Figure 2, shows that the standard was met in quarter 1 of 2019/ 20 and for July 2019. During this period there were no assessments carried out in an acute setting, which is a better experience for patients. Figure 2: Percentage of decision support tool (DST) assessments carried out in an acute setting.

Period Number of

DSTs carried out

Number of DST carried out in an acute hospital setting

% of DST carried out in an acute hospital

setting Target

Quarter 1 18/19 33 2 6%

<15%

Quarter 2 18/19 29 8 28%

Quarter 3 18/19 37 11 30%

Quarter 4 18/19 30 0 0%

Quarter 1 19/20 18 0 0%

July 2019 18 0 0%

Due to the efficiencies realised through the discharge to assess (D2A) pilot in 2018, from April 2019 Islington has moved the D2A resource into the core CHC service to ensure the continued achievement of less than 15% of care assessments taking place in an acute setting. In line with other NCL CCGs, all referrals will be processed using the NCL D2A Checklist via a single point of access team. This will ensure that patients are moved out of an acute setting as appropriate enabling CHC teams to focus on patient assessments. Assurance of the process is being monitored via monthly quality review meetings with Whittington Health.

2.3.2 Continuing Healthcare (CHC) referrals that are completed within 28 days

The target for the percentage of ‘standard’ continuing health care referrals that are completed within 28 days is 80%. Figure 3, shows that Islington has not met this standard since quarter 2 of 2018/ 19. Performance has been below standard due to delays in hospital discharges and decision-making as well as an incorrect assessment of the level of care required for an individual. The CHC team implemented an improvement plan in quarter 1 of 2019/ 20 to improve performance. The actions included;

Escalation via senior managers in key stakeholders;

Proactive identification of possible delays by CCG local authority and clinical team.

Senior line management proactively supporting front line staff, both clinical and social care staff.

Case assessment issues shared to encourage engagement with all concerned.

Will consider a whole system social worker whose focus is CHC, whereby they are the beacon of CHC good practice.

There was a significant improvement (+22%) in performance in July, the first month of quarter 2 and it is anticipated that performance will improve so that at least 80% of cases are completed within 28 Days by the end of quarter 2.

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Figure 3: Percentage of continuing health care referrals that are completed within 28 days.

2.4 Whittington Health (WH) Community Health Services (CHS) The June 2019 performance for each service for urgent and routine referrals against the maximum and average waiting time is shown in the Whittington Health NHS Trust Quality and Performance Dashboard and is available as a link within the September Governing Body papers for information. 2.4.1 Community Services Transformation Work The community services transformation work is overseen by the Community Services Improvement Group (CSIG). The key points for the committee to note for the period to the end of June are;

● Adult CSIG has moved to being a bi-monthly meeting with monitoring on a regular basis by the Adult Community Service senior managers. This includes review of waiting time and other projects around the improvement plan.

● A group of services are consistently meeting the trajectory for waiting times and this has been maintained for June (diabetes, respiratory, lymphedema and tissue viability).

● A quality improvement approach is being taken for other services. ● Podiatry performance is at 84%. This is an improvement from May. There are a number of

reasons why performance is below trajectory (an accumulated backlog, staff sickness and some administrative errors) all of which are being investigated.

● The continence service performance is static at around 50% of patients seen within 12 weeks and the working group is actively taking forward exploring re-modelling of the offer to provide a single point of access.

● MSK waiting times for routine physiotherapy are being maintained at an average of 5 weeks. However, the waiting time for advance physio (CATS) is lower due to planned and unplanned leave and higher than forecast referrals. Blitz clinics and recruitment are underway.

● Integrated Community Therapy team (ICTT) performance is on track for broad rehabilitation but lower than target for stroke and neuro rehabilitation. A targeted review is being undertaken over the next eight weeks to establish the causes of this and how they might be addressed.

2.5 Children and Adolescent Mental Health Services (CAMHS) Community CAMHS deliver a range of treatment and interventions for children and young people (CYP) within their services in the community. The waiting time target specified within the contract specification is a referral to treatment (RTT) of 8 weeks. CAMHS previously delivered the CAPA model (Choice and Partnership Approach) within which this RTT was specified as 8 weeks (4/4) outlining with a 4 week wait to the choice appointment and then no more than a further 4 weeks to partnership (ongoing treatment). At Quarter 1 2017/18 waiting times stood at 24.3 weeks’ referral to treatment.

Period Standard CHC

referrals completed

Number of referrals completed within 28

days

% Standard CHC referrals completed within 28 days

Target

Quarter 1 18/19 45 30 67%

>80%

Quarter 2 18/19 29 26 90%

Quarter 3 18/19 45 22 49%

Quarter 4 18/19 27 11 41%

Quarter 1 19/20 40 20 50%

July 2019 18 13 72%

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In July 2018, a contract performance notice (CPN) was issued to Whittington Health Community CAMHS in respect of its waiting times for its core emotional and behaviour pathways. Since July 2018, as part of the CPN process the CCG have been meeting on a monthly basis with Whittington Health CAMHS and have a remedial action plan in place that is reviewed at each meeting. CAMHS now operates a new internal model that does not split choice and partnership work. Referrals coming in to CAMHS are also now triaged by a multi-agency intake partnership, including community providers, as part of the Children and Young People Social, Emotional and Mental Health Service Redesign (CYP SEMH). Referrals are allocated to the appropriate service and all referrals now go straight in to treatment after their first assessment with the same clinician. The exception of this is with extremely complex cases, which may need further assessment. As a result of these measures, and those listed below, the waiting time from referral to first appointment has now decreased to approximately 17 weeks from referral to treatment (June 2019). Further measures to achieve a RTT of 8 weeks by December 2019;

An internal restructure within CAMHS has been implemented creating additional clinical capacity- 90% of posts within the new CAMHS restructure are now filled.

The new CAMHS Clinical Lead and Associate Director posts for CAMHS at Whittington Health (new post) to support leadership have now commenced and actively engaged with commissioners and governance meetings.

Detailed data review and analysis to determine activity levels, did not attends (DNAs) and level of referrals that come into the specialist service but are the closed shortly after – a new internal approach has now seen a decrease in DNAs from around 15% in July 2018 to 13% in June 2019 and is predicted to continue on a downward trend.

Additional short term funding was secured from NHS England (NHSE) to fund 3 short term posts to address waiting lists and additional Psychiatry session which can provide a specific focus on behaviour pathway and in particular ADHD cases. These posts have been actively addressing the waiting lists for partnership appointments within the previous service model.

The Children and Young People Social, Emotional and Mental Health Service Redesign (CYP SEMH) being led by commissioners, to provide broader service offer, utilising counselling and therapeutic services in voluntary community faith sector (VCSF), digital offer and use of social prescribing and self -management where thought to be clinically appropriate. The project is being implemented in two stages. Stage one, the emotional wellbeing pathway, commenced on June 24th 2019 from the Northern Health Centre (Community CAMHS premises). Stage two, full integration of CAMHS and the emotional wellbeing pathway within the Children’s Services Contact Team (CSCT) at Upper Street, will launch on 30th September 2019 after a pilot period from mid- August 2019.

The last report waiting time report, presented by the CAMHS Associate Director at the July 2019 CPN meeting, confirmed a waiting times trajectory of 9 weeks from RTT by the end of December 2019. 2.6 Mental Health Performance The full report showing performance of the mental health standards is reported in the August NCL Mental Health Performance and Quality Report and is available as a link within the September Governing Body papers for information. Islington CCG achieved the following mental health key performance indicators for the last reporting period. These were:

The percentage of Referral to Treatment (RTT) first episode psychosis (FEP) periods within 2 weeks of referral for June 2019 was achieved with performance of 83.3%, against a target of 56%;

The proportion of admissions to acute wards that were “gate-kept” by the crisis resolution home treatment team (CRHT). Gatekeeping involves assessing the service user before admission to hospital to consider whether there are alternatives to admission. The standard for quarter 1 of 2019/20 was achieved with performance of 98.3%, against a target of 95%;

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The proportion of Islington CCG patients on a care programme approach (CPA) who were followed up within 7 days after discharge from psychiatric inpatient care for quarter 1 of 2019/20 with performance of 97.6%, against a target of 95%.

The dementia diagnosis rate (Age 65+) for July 2019 was achieved with performance of 91.4%, against a target of 67.0%;

Children’s and young people’s access to treatment for quarter 1 of 2019/ 20 was achieved with performance of 15.1%, against an expected rate of 8.5%;

The proportion of children and young people with eating disorders (urgent cases) that wait 1 week or less form referral to start of NICE-approved treatment for quarter 1 of 2019/20 was achieved with performance of 100%, against a target of 95% and;

The indicators that did not achieve their performance were:

Physical Health Checks for People with Severe Mental Illness for quarter 1 of 2019/20 with performance of 33.4%, against a target of 50%. The performance reported is lower than will actually be the case due to a data capture issue within primary care. The current figure only reports health checks that have been carried out within the Integrated Practice Unit. Work is being undertaken to ensure that health checks carried out by the SMI nurse in primary care are being captured and that these will be included in future returns.

Memory services referral-to-diagnosis 6 week wait for June 2019 with performance of 50%, against a target of 85% although an improvement from 37.5% in May 2019. The provider, Camden and Islington Foundation Trust (CIFT), has seen a drop in performance recently for both the Islington and Camden borough. One contributory factor has been the long waits for MRI scans needed to confirm diagnosis and reports. This is being addressed with a piece of work taking place across the STP. However, when reviewing the average wait to receive a diagnosis for Islington, the average wait improved from 7.7 weeks in quarter 4 of 2018/19 to 6.7 weeks in May 2019.

The proportion of children and young people (CYP) with eating disorders (routine cases) that wait 4 weeks or less from referral to start of NICE-approved treatment for quarter 1 of 2019/20 with performance of 86.4%, against a target of 95%. The standard was not achieved for Islington due to two cases seen by Barnet, Enfield and Haringey Mental Health Trust (BEHMT). BEHMT are not currently working to the national CYP eating disorder standard, as they are not funded to meet this. This has been discussed with the trust. As these cases are a small number of the total activity the CCG has asked that when the provider accepts the referral it should be made a priority and treated within the 4 week target.

2.6.1 Improving Access to Psychological Therapies Standards (IAPT) There are four main improving access to psychological therapies standards. Islington CCG achieved the following IAPT standards for the last reporting period. These were:

The proportion of people that wait 6 weeks or less from referral to entering a course of IAPT treatment was achieved with performance of 77% in April 2019, against a target of 75% and;

The proportion of people that wait 18 weeks or less from referral to entering a course of IAPT treatment was achieved with performance of 99% in April 2019, against a target of 95%;

The recovery rate with performance of 54.0% for April 2019, against the target of 50%.

The indicator that did not achieve their performance was:

The access rate with performance of 1.4% for April 2019, against a target of 1.58%. Provisional local data indicates that the access rate remained at 1.4% for May 2019.

A Service Development Improvement Plan (SDIP) is in place to ensure Camden & Islington Foundation Trust (CIFT) achieve the increased access target for 2019/ 20.

Improvements include:

Rolling out outreach workshops to increase take-up among young adults including students

Increasing the contribution to IAPT access from among the voluntary sector IAPT supply chain

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Broadening the target groups within the Long Term Conditions IAPT cohort (to increase cardio rehab)

Increasing the volume of people accessing digital and on line IAPT interventions.

2.6.2 Mental Health Inappropriate Out of area placements An inappropriate out of area placement (OAP) is where there are no appropriate beds available at the local provider and the patient has been placed either in another NHS provider or in the private sector, in some cases miles from home and from their local services where they are known. This is an area of particular focus, and there is a national standard that there will be no inappropriate out of area placements by 2020/ 21. The number of bed days where patients are placed out of area for Islington CCG has decreased from 135 in December 2018 to 5 in May 2019, the lowest across NCL in that month. 2.6.3 Mental Health Delayed Transfer of Care (DToC)/ Length of stay on acute wards The local standard is 1.8% and Camden & Islington Foundation Trust (CIFT) are reviewing the methodology to include the rehabilitation wards. The number of bed days lost at CIFT decreased from 314 in February 2019 to 180 in June 2019. 2.6.4 Mental Health Related 12-Hour Breaches The way in which mental health related breaches are recorded has recently changed with a standardised approach across all providers. Therefore In recent months, the number of breaches has increased, with a focus on reducing the amount of time mental health patients spend in A&E and assessed in the correct environment. There were twelve reported 12-hour mental health breaches (subject to validation) in A&E at Whittington Health in July 2019. The majority of the breaches were in relation to the Camden & Islington Foundation Trust (CIFT). All 12-hour breaches were due to delays in transferring patients to appropriate mental health beds following assessment by local psychiatric liaison teams. This is being address jointly by all relevant stakeholders by reviewing current capacity, processes and mental health pathways to reduce the number of breaches and improve the overall experience of mental health patients in A&E. There is going to be an NCL STP summit on Mental Health ED breaches on 20 September 2019. 2.7 Quality premium (QP) 2018/ 19 The 2018/19 QP scheme was described in detail within the July 2018 Governing Body Performance report. The QP award is based on measures that cover a combination of national and local priorities and reflect the quality of the health services commissioned. There are two emergency demand indicators, five national quality indicators and one local measure. In keeping with the 2017/18 Quality Premium, the maximum payment for a CCG is expressed as £5 per head of population, calculated to the same methodology as for CCG running costs, and made as a programme allocation (this is in addition to a CCG’s main financial allocation and its running costs allowance). The total potential value of the quality premium for Islington CCG for performance relating to 2018/19 was £1.14M. Based on actual performance across 2018/19 the expected value of the quality premium payment, which Islington CCG should receive for the 2018/19 performance, is £429K. Payment is usually received by the CCG in the December or January of the following financial year (i.e December 19 / January 20 in relation to the 2018/19 period).

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9

As per the quality premium guidance, the 2018/19 quality premium payment will be conditional on the CCG meeting the quality and financial gateways as described in the July 2018 Governing Body Performance report. Islington CCG met both gateways for the financial year 2018/19. 2.7.1 Quality premium (QP) 2019/ 20 Even though we are already part way through 2019/20 the guidance for the 2019/ 20 QP scheme has not yet been published by NHSE/ I. When this has been made available, the Governing Body will be informed. 2.8 Improvement and Assessment Framework (IAF) 2018/ 19

In July 2019, the 2018/19 CCG performance assessment was published. All 195 CCGs are rated annually under a CCG IAF so the public can easily see how their CCG is performing. CCGs are assessed on financial performance, delegated functions and planning, as well as how well led they are. Islington CCG was rated by NHSE as “good” in its 2018/19 assessment, this followed on from a 2017/18 rating of “good”. Figure 4 shows the assessment rating for the IAF for 2017/18 and 2018/19 across the five NCL CCGs. Figure 4: Summary of performance across NCL CCGs The 2019/20 IAF framework has not yet been published by NHSE/ I. The framework will be shared with the Governing Body once it is published.

CCG Overall 2017/18 rating Overall 2018/19 rating

Barnet Requires improvement Requires improvement

Camden Good Good

Enfield Requires improvement Requires improvement

Haringey Requires improvement Requires improvement

Islington Good Good

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Islington Clinical Commissioning Group Meeting: Governing Body Meeting Date: 11 September 2019

Report Title Board Assurance Framework

Date of report

19 August 2019

Agenda Item 5.1

Lead Director /

Manager

Alex Smith, Director of Planning and Delivery

Tel/Email alexander.smith1@nhs.net

GB Member Sponsor

Report Author

Jennifer Nabwogi, NCL Governance & Risk Lead

Tel/Email Jennifer.nabwogi@nhs.net

Name of

Authorising

Finance Lead

N/A Summary of Financial Implications

The BAF report supports the CCG in managing its most significant financial risks.

Report Summary

This report is the Governing Body Board Assurance Framework (‘BAF’). It captures the most serious risks to the achievement of the CCG’s strategic objectives.

Risks on the BAF currently have a score of 12 or higher but may have a lower score where the risks are material to the achievement of a strategic objective and are escalated for Governing Body visibility.

Key risks from the NCL Primary Care Co-Commissioning Committee in Common (‘NCL PCC’) Risk Register, NCL Joint Commissioning Committee (‘NCL JCC’) Risk Register and NCL Risk Register are reported to the Governing Body to ensure visibility and oversight. Risks from the NCL JCC Risk Register and the NCL Risk Register are from an NCL perspective. However, risks from the NCL PCC Risk register can be from either a local perspective or a pan NCL perspective depending on the risk.

Board Assurance Framework (‘BAF’) There are 6 risks on the BAF with no new risks. Two risks have decreased in their scores. All other risks have remained constant at their current levels and have neither improved nor worsened. The full version of the Islington CCG BAF can be found here. Key Highlights: Risk 439 - Due to the CCG's inability to control demand management schemes on its own (demand management schemes require system cooperation and a change in system behaviour in order for them to yield positive results), there is a risk that acute activity will exceed the CCG contracted plan during 2019/20. This may have a negative impact on the ability of the CCG to meet the Financial Control

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Total in 2019/20. A number of demand management schemes have been identified however, there is a level of risk associated with delivery of these schemes. In parallel, there is an agreement that the CCGs and Whittington Health (as main acute provider) will work together to pro-actively monitor demand trends that are being seen in activity delivered by the Trust in-year. This is to ensure that any unexpected changes are identified expediently and mitigations agreed in time. Oversight committee: Strategy and Finance. Current Risk Rating: 20. Reducing risks The scores of the following risks have decreased since the last Governing Body meeting. Risk 440 - Due to the requirement for substantial changes to models of care and clinical behaviour across our health economy, there is a risk of slippage within the 2019/20 QIPP programme delivery. This may negatively impact the CCG's ability to meet the Financial Control Total in 2019/20. £12.98m of potential savings have been identified with 63% (£8.16m) of these being transformational schemes associated with managing demand for acute services. There are significant risks to the delivery of the plan, with only a proportion of it being agreed with acute provider contract values. The first set of acute related data on QIPP has been made available during August 2019 but there are some data quality limitations that are being worked through. Should slippage be experienced, there are a limited number of further opportunities for savings available to the CCG within the current QIPP pipeline that would require additional clinical and commissioner capacity to scope and plan. As a result of these risks, from July 2019, the Executive Management Team has been undertaking reviews of every budget line to ensure potential financial recovery actions can be robustly identified. In addition STP wide work is continuing on the identification of a Medium Term Financial Strategy. The risk score has however decreased from 20 to 16 as a result of moderation of risk scores across NCL. Oversight committee: Strategy and Finance. Current Risk Rating: 16. Risk 441 - Due to the pressures around QIPP delivery, increase in acute activity, pressures in Prescribing and high levels of CHC demand, there is a risk of failure to meet the Financial Control Total in 2019/20. This may lead to damage to the CCG's financial position and the inability to invest as desired to improve patient care: The CCG has reported to NHS England at month 4 that the financial plan will be met in Islington CCG. The original risks reported within the operating plan of £2.7m are still present with limited reserves available to offset these pressures. The CCG has received limited information from the Commissioning Support Unit (CSU) with regard to year to date and forecast activity from in-sector acute providers and the CSU has provided appropriate challenge to the data received. There is continued NCL-wide work on the Medium Term Financial Strategy which is being developed between provider Trusts and CCGs across the NCL STP. Other external pressures relating to Primary Care and Continuing Healthcare services have been added to the risk. In addition to these risks, the comments within risk 440 (QIPP) should be noted as these will directly affect the ability of the CCG to achieve the financial plan. The limited value of identifiable reserves adds to this risk as these reserves were used to offset QIPP slippage in 2018/19. The risk score has decreased from 20 to 12. Oversight committee: Strategy and Finance. Current Risk Rating: 12.

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Risk removed from the BAF: The following risk has been removed from the BAF and the CCG risk register since it was last presented to the Governing Body in June 2019. Risk 420 - Moorfields - There is a risk of poor service provision and ineffective governance systems due to the lack of formally agreed service level (SLA) contracts across satellite site. This in turn restricts the drive for improvement, standardising of practices and influencing of change which can lead to poor patient outcome and experience. The CQC inspection report was presented to the May 2019 CQRG meeting. The Trust is developing an action plan in response to recommendations made in the report. The Trust has good governance processes in place for reporting implementation of the action plan to the Trust Board. Oversight committee: Quality and Performance. Risk score at closure: 12 NCL Risk Register There are 14 risks on the NCL Risk Register with 1 risk having a current risk score of 15 or higher. Three change programme risks and a Brexit risk have been identified and have been added to the NCL risk register. These include risk on:

Destabilisation as a result of the UK leaving the European Union;

Failure to deliver an Integrated Care System;

Failure to deliver the mandated twenty percent management cost reductions;

Failure to merge the five CCGs.

The full version of the NCL Risk Register can be found here. Key Highlights: NCL9: Delivering Financial Balance across the NCL CCGs. At 18/19 outturn (subject to audit) NCL CCGs reported a combined deficit of £50.7m. There were deficits at Barnet £9.6m, Enfield £24.8m, Haringey £17.9m offset by surpluses of Islington £1.5m and Camden £0.1m. For 19/20 CCGs have submitted a combined deficit of £41m with a net additional risk of £22m. It will be challenging to manage this net risk during 19/20. NCL CCGs will be developing a Medium Term financial strategy in the Spring/Summer as part of the STP requirement for the NHS Long term plan. The Medium Term financial strategy will include a plan to bring the NCL STP health economy into balance over the next 2/3 years. At Month 4 all CCGs remain on Plan, though risks (particularly in primary care with GP@Hand) are growing. This risk is rated 20. NCL11: Destabilisation as a result of the UK’s planned exit from the European Union. NHSE preparatory work was suspended in the Spring following the Government’s announcement of the revised timescales for the United Kingdom to exit the European Union. At the point of suspension all NCL CCGs were fully compliant with requirements. Further preparatory steps are expected in September 2019 and, in liaison with NHS England, the NCL CCGs will continue to manage and support readiness arrangements. The risk to the wider health care system is greater than to the NCL CCGs’ operation. The NCL CCGs will support the wider system, including Trusts and Primary Care, in liaison with NHSE. This risk is rated 9. NCL12: Failure to deliver an Integrated Care System (ICS) across the North Central London (NCL) CCGs. NCL has established an NCL-wide task and finish group on Integrated Care System design, working alongside developing local integrated care partnerships at borough level. An engagement advisory board is in place to help shape engagement with residents across NCL on these developments. This risk is rated 8.

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NCL13: Failure to deliver NHS England 20% management costs reduction. A detailed review has now taken place to fully understand the financial savings required to deliver the 20% reduction in time for 2020/21. The required reductions in management costs would be deliverable through the proposed NCL CCGs’ merger from April 2020. In the event of the merger not proceeding to this timescale a revised reduction plan will be required. This risk is rated 9. NCL14: Effective Delivery of Corporate Merger. Significant work has gone into the development of plans to deliver a merger of the five North Central London CCGs, and these continue to progress at pace. There remains significant risk that key issues that impact on the ability of CCG members, stakeholders, and partners to support the formal corporate merger of the CCGs will not be resolved in time to allow this to happen as planned on 1st April 2020. The work to move to a single CCG structure and to support ICS and ICP development will continue regardless of the date of the merger. This risk is monitored on a very regular basis by NCL SMT and the NCL Assurance and Oversight Group. This risk is rated 12. NCL Primary Care Commissioning Committee in Common Risk Register There are 7 risks on the NCL Primary Care Co-Commissioning Committee in Common (‘NCL PCCC’) Risk Register with 1 risk having a current risk score of 15 or higher. Risk PCCC 24 (The Establishment of Primary Care Networks, as set out in the new national GP contract needs to align with local primary care strategies and primary care provision including GP Federations, and avoid potential conflicts of interest) is included in this report to highlight the risk to the Governing Body. The NCL PCCC Risk Register can be found here. Key Highlights: PCCC18: Inadequate support from Primary Care Support England (Capita contract) for general practices. Capita have recommenced the patient list cleansing process in agreement with NHS England. The London process will start in North Central London. The timeline for the list cleansing process, requested by the Committee in April 2019, is set out below:

Current - people aged over 100 on practice lists;

From June 2019 – People under 16 and demolished properties; From September 2019 - homes with high multiple occupancy, students (this may be moved forwards), and transient population. This risk is rated 16. PCCC24: The Establishment of Primary Care Networks, as set out in the new national GP contract needs to align with local primary care strategies and primary care provision including GP Federations, and avoid potential conflicts of interest. The following work has been undertaken to manage the establishment of primary care networks (PCNs): • Establishment of PCNs in NCL in line with national guidance including geographic coherence and population size, and through a bottom-up process with practices and the Local Medical Committee; • Approval of PCN proposals across NCL by the Committee in June 2019; • Organisation development programme being developed for Clinical Directors of the PCNs; • Establishing primary care provider meetings to align the work of GP Federations and PCNs; • Amendment of declarations of interest to include PCN membership for general practice members of CCG Governing Bodies and Committees. This risk is rated 9.

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NCL Joint Commissioning Committee Risk Register There are 7 risks on the NCL Joint Commissioning Committee (NCL JCC’) Risk Register with 2 risks having a current risk score of 15 or higher. The NCL JCC Risk Register is being further developed and strengthened so the detailed register is not included and instead the strategic highlight report can be found here. Key Highlights: JCC13: Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat). In addition to After action reviews for winter 2018/19 relating to delivery of the four hour A & E waiting time standard: • Surge hub support, provided by Northeast London Commissioning Support Unit (NELSCU), has been extended from 5 days to 7 days for the winter period. The surge hub support delivery of escalation actions as urgent and emergency care system pressure increases; • Operating plan profiles elective activity to minimise routine work at times of peak demand for emergency pathways. Capacity for emergency surgery and cancer maintained over the winter period; • Plans to reduce extended lengths of stay (over 21 days) by 40% by March 2019 compared to March 2018 with weekly discharge profiles submitted to encourage reducing this patient cohort; • Plans to eliminate ambulance handovers waits into emergency departments in excess of 30 minutes from October 2019; • Plans to increase GP streaming in emergency departments. This risk is rated 16. JCC28: Supporting system financial recovery through contracts (Threat). Mitigations underway include: • Workshops to develop medium-term financial strategy for NCL held on 3 May and 19 July 2019, focusing on both recovery actions for 2019/20 and developing actions for the medium-term to bring NCL as a system into financial balance; • NCL-wide and Borough-based “Intergreat” events held with NCL STP stakeholders to simulate the introduction of local integrated care systems. The outcome will inform planning for 2019/20; • Establishment of Local Delivery Groups with providers to support delivery of QIPP and provider cost improvement programmes; • Financial plans for 2020/21 are being developed in preparation for submission of the NCL response to the NHS Long Term Plan. First cut plans will go to the STP Directors of Finance meeting on 26 July 2019 for consideration; • Cap and collar constructs have been agreed for the contracts with Royal Free London and North Middlesex University Hospital for 2019/20, and a block contract for UCLH in 2019/20 and 2020/21. This risk is rated 20. Risk Appetite Scores On 15 August 2019 the Governing Body met to discuss and agree its risk appetite scores in accordance with the CCG’s risk management strategy and policy. The risk appetite scores set the high level principles underpinning the CCG’s approach to each area of risk and risk culture. The new risk appetite scores are found at appendix 1 of this report.

Recommendation The Governing Body is asked to REVIEW the BAF and provide feedback on the

risks.

Identified Risks

and Risk

Management

Actions

The BAF is a risk management document which highlights the most significant

risks to the achievement of the CCG’s strategic objectives.

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Conflicts of Interest

Conflicts of interest are managed robustly and in accordance with the CCG’s conflict of interest policy.

Resource

Implications

Updating of the BAF is the responsibility of each risk owner and their respective

directorates. The Governance Team helps to support this by providing monitoring,

guidance and advice.

Engagement

The BAF report is presented at each Governing Body meeting. The Governing

Body includes clinicians, lay members and representatives of patients and other

key stakeholders.

Equality Impact

Analysis

This report has been written in accordance with the provisions of the Equality Act

2010.

Report History

and Key

Decisions

The BAF was last reviewed by the Governing Body in June 2019. Risks are kept

under review by the risk owners and by the committees of the Governing Body.

Next Steps To continue to manage risk across the organisation in a robust way.

Appendices

The following documents are included:

Islington CCG BAF Highlight Report

Appendix 1 – Risk Appetite Scores

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GBAF tracker September 2019

Risk ID Risk Title Risk Owner Strategic Update JAN MAR JUN SEPT

108 If the CCG is inneffective in

developing the primary care

workforce, there is a risk that it

will not deliver the primary care

strategy. This could mean that,

for example, patients with long

term conditions are not fully

supported in primary care and

require more frequent hospital

care.

Sarah Mcilwaine,

Programme

Director, Health

and Care Closer to

Home (North

London Partners)

Four primary care networks (PCNs) have been established across Islington. Clinical Directors have

been appointed. Recruitment for social prescribers will soon commence plus that of additional

pharmacy roles. The baseline of staffing has been completed for NHS England. The PCNs are

mostly still to be recruited to.

Allocations for GP Retention within the GP Forward View have been confirmed and work is

underway to establish proposals against this funding.

Oversight: Strategy and Finance Committee.

12 12 12 12 9

419 Due to current poor

performance against existing

contract specifications, there is

a risk that the Trust will not be

able to meet the KPIs set out in

service specifications for

community services. This

increases the likelihood of

harm, discomfort and poor

quality outcomes for patients as

a result of the longer waits.

Jennie Williams,

Director of Nursing

and Quality

There have been no escalations of quality concerns to CQRG via the Community services

improvement group (CSIG). The CSIG is currently tasked with monitoring the improvements of

waiting times in community services.

Oversight: Quality and Performance Committee.

12 12 12 12 6

423 Due to current deviation from

national guidelines on the

treatment and management of

LUTs (adults), there is a risk

that the agreed specifcation for

the 2018/19 Lower Urinary

Tract Symptoms (LUTS) may

not be met. This would lead to

poor patient outcomes and

experience.

Jennie Williams,

Director of Nursing

and Quality

The CCG has received the revised Lower Urinary Tract Symptom (LUTs) protocol from the Trust

and is liaising with NHS England to secure an external opinion on the revised LUTs protocol.

Oversight: Quality and Performance Committee.

12 12 12 12 6

439 Due to the CCG's inability to

control demand management

schemes on its own (demand

management schemes require

system cooperation and a

change in system behaviour in

order for them to yield positive

results), there is a risk that

acute activity will exceed the

CCG contracted plan during

2019/20. This may have a

negative impact on the ability of

the CCG to meet the Financial

Control Total in 2019/20.

Alice Tertois,

Assistant Director

of Contracts

A number of demand management schemes have been identified however, there is a level of risk

associated with delivery of these schemes. In parallel, there is an agreement that the CCGs and

Whittington Health (as main acute provider) will work together to pro-actively monitor demand trends

that are being seen in activity delivered by the Trust in-year. This is to ensure that any unexpected

changes are identified expediently and mitigations agreed in time.

Oversight: Strategy and Finance Committee.

20 20 20 15

Islington CCG BAF Risks - Highlight Report2019/20

Movement From

Last Report

Target Risk

ScoreCurrent Risk Score

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GBAF tracker September 2019

440 Due to the requirement for

substantial changes to models

of care and clinical behaviour

across our health economy,

there is a risk of slippage within

the 2019/20 QIPP programme

delivery. This may negatively

impact the CCG's ability to meet

the Financial Control Total in

2019/20.

Alex Smith,

Director of

Planning and

Delivery

£12.98m of potential savings have been identified with 63% (£8.16m) of these being

transformational schemes associated with managing demand for acute services. There are

significant risks to the delivery of the plan, with only a proportion of it being agreed with acute

provider contract values. The first set of acute related data on QIPP has been made available during

August 2019 but there are some data quality limitations that are being worked through. Should

slippage be experienced, there are a limited number of further opportunities for savings available to

the CCG within the current QIPP pipeline that would require additional clinical and commissioner

capacity to scope and plan. As a result of these risks, from July 2019 the Executive Management

Team has been undertaking reviews of every budget line to ensure potential financial recovery

actions can be robustly identified, in addition STP wide work is continuing on the identification of a

Medium Term Financial Strategy. The risk score has however decreased from 20 to 16 as a result of

moderation of risk scores across NCL.

Oversight committee: Strategy and Finance.

16 20 16

12

441 Due to the pressures around

QIPP delivery, increase in acute

activity, pressures in

Prescribing and high levels of

CHC demand, there is a risk of

failure to meet the Financial

Control Total in 2019/20. This

may lead to damage to the

CCG's financial position and the

inability to invest as desired to

improve patient care:

Simon Goodwin,

CFO

The CCG has reported to NHS England at month 4 that the financial plan will be met in Islington

CCG. The original risks reported within the operating plan of £2.7m are still present with limited

reserves available to offset these pressures.

The CCG has received limited information from the Commissioning Support Unit (CSU) with regard

to year to date and forecast activity from in-sector acute providers and the CSU has challenged the

data received. There is continued NCL-wide work on the Medium Term Financial Strategy which is

being developed between provider Trusts and CCGs across the NCL STP. Other external pressures

relating to Primary Care and Continuing Healthcare services have been added to the risk. In

addition to these risks, the comments within risk 440 (QIPP) should be noted as these will directly

affect the ability of the CCG to achieve the financial plan. The limited value of identifiable reserves

adds to this risk as these reserves were used to offset QIPP slippage in 2018/19. The risk score has

decreased from 20 to 12.

Oversight: Strategy and Finance Committee.

20 20 12

20

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Schedule 2 Risk Appetite

This schedule sets out the CCG’s risk appetite as agreed by the Governing Body on 15 August 2019 The chart below shows the appetite grading for risks based on their potential impact

Appetite Description Appetite

Level

The CCG is not willing to accept these risks under any circumstances 1

The CCG is not willing to accept these risks (except in very exceptional

circumstances)

2

The CCG is willing to accept some risk in this area 3

The CCG is willing to accept moderate risk in this area 4

The CCG is willing to accept high risk in this area 5

The chart below shows the CCG’s risk appetite in each area:

No. Service Area Governing Body Statement Appetite

Level

1. Quality We will ensure equitable, high quality services for all the

people of the borough and will only rarely accept risks

which threaten that goal.

2

2. Safety We hold patient and staff safety as the highest priority and

will not accept any risk that threatens either.

1

3. Compliance with

legislation

We will comply with all legislation relevant to the CCG and

will not accept any risk which, if realised, would result in

non-compliance except in very exceptional

circumstances.

(Excludes compliance with national targets)

2

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4. Conflicts of

Interest

We will preserve the integrity of our decision making

processes and our decisions and will comply with statutory

guidance. Given the nature of CCGs and the challenges

of delivering national and local plans such as the Five Year

Forward view we are willing to accept some risks in certain

circumstances but these will be managed robustly.

2

5. Reputation We intend to maintain high standards of conduct and will

accept risks that may cause reputational damage only in

certain circumstances, and only when the benefits merit

the risk.

3

6. Innovation &

Productivity

We aim to foster, and will encourage, a culture of

innovation and efficiency; in so doing we are prepared to

accept the concomitant risks. However, when doing so we

will work within the risk appetite levels for each Service

Area set out in this document and will not exceed them.

4

7. Finance We will stay within set financial limits and will not accept

any risks which, if realised, would cause a breach but the

achievement of strategic objectives, value for money and

cost effectiveness can justify calculated risk.

2

8. Partnerships We will work with other organisations to ensure the best

outcome for patients and are willing to accept the risks

associated with a collaborative approach.

3

Precedence of Risk Appetite Scores For the avoidance of doubt where two risk appetite scores conflict with each other the lowest risk appetite score takes precedence. For example, the CCG may be working on a new and innovative service and so work within the risk appetite level of 4 for Innovation and Productivity. However, whilst doing so the CCG will work within the risk appetite levels of 1 for Safety and 2 for Quality.

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Risk Scoring Key This document sets out the key scoring methodology for risks and risk management.

1. Overall Strength of Controls in Place There are four levels of effectiveness:

Level Criteria

Zero The controls have no effect on controlling the risk.

Weak The controls have a 1- 60% chance of successfully controlling the risk.

Average The controls have a 61 – 79% chance of successfully controlling the risk

Strong The controls have a 80%+ chance or higher of successfully controlling the risk

2. Risk Scoring

This is separated into Consequence and Likelihood. Consequence Scale:

Level of Impact on the Objective

Descriptor of Level of Impact on the Objective

Consequence for the Objective

Consequence Score

0 - 5% Very low impact Very Low 1

6 - 25% Low impact Low 2

26-50% Moderate impact Medium 3

51 – 75% High impact High 4

76%+ Very high impact Very High 5

Likelihood Scale:

Level of Likelihood the Risk will Occur

Descriptor of Level of Likelihood the Risk will Occur

Likelihood the Risk will Occur

Likelihood Score

0 - 5% Highly unlikely to occur

Very Low 1

6 - 25% Unlikely to occur Low 2

26-50% Fairly likely to occur Medium 3

51 – 75% More likely to occur than not

High 4

76%+ Almost certainly will occur

Very High 5

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3. Level of Risk and Priority Chart

This chart shows the level of risk a risk represents and sets out the priority which should be

given to each risk:

LIKELIHOOD

CONSEQUENCE

Very Low

(1)

Low (2)

Medium (3)

High (4)

Very High

(5)

Very Low (1)

1 2 3 4 5

Low (2)

2 4 6 8 10

Medium (3)

3 6 9 12 15

High (4)

4 8 12 16 20

Very High (5)

5 10 15 20 25

1-3

Low Priority

4-6

Moderate Priority

8-12

High Priority

15-25

Very High Priority

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Islington Clinical Commissioning Group Meeting: Governing Body Meeting Date: 11 September 2019

Report Title NCL Primary Care Commissioning Committee in Common Terms of Reference

Date of report

22nd August 2019

Agenda Item

5.2

Lead Director /

Manager

Paul Sinden, Director of Planning, Performance and Primary Care

Tel/Email p.sinden@nhs.net

GB Member Sponsor

Report Author

Andrew Spicer, Head of Governance and Risk- NCL CCGs

Tel/Email andrew.spicer1@nhs.net

Name of

Authorising

Finance Lead

N/A Summary of Financial Implications

None.

Report Summary

At the Governing Body meetings in June 2019 it was agreed that the Terms of Reference for the NCL Primary Care Commissioning Committee in Common (‘Committee’) would be amended to include deputations. The Terms of Reference were amended accordingly and approved by the Committee at its meeting on 22nd August 2019. The amendments are highlighted as tracked changes for ease of reference.

Recommendation The Governing Body is asked to REVIEW and APPROVE the revised Terms of Reference.

Identified Risks

and Risk

Management

Actions

The revisions to the Terms of Reference clarify the rules by which the Committee deals with deputations.

Conflicts of Interest

The Terms of Reference set out the arrangements by which the Committee manages conflicts of interest.

Resource

Implications

Not applicable.

Engagement

This paper was presented to the Committee which includes lay members and clinicians from each of the five NCL CCGs.

Page 111 of 131

Equality Impact

Analysis

This report has been written in accordance with the provisions of the Equality

Act 2010.

Report History

and Key

Decisions

The revised Terms of Reference were presented to the Committee on 22nd

August 2019 and were approved. Previously the Terms of Reference were last

reviewed by the Committee on 21st February 2019 and approved by Governing

Bodies in March 2019.

Next Steps If the Governing Body approved the revised Terms of Reference the next step is to put them into operation.

Appendices

None.

Page 112 of 131

NCL Primary Care Commissioning Committee in Common

Terms of Reference

1. Introduction 1.1 In 2017 the five Clinical Commissioning Groups (‘CCGs’) within North Central London

(‘NCL’) agreed to work together in exercising Primary Care commissioning functions, as delegated to the CCGs by NHS England under 13Z of the National Health Service Act 2006 (as amended) (‘NHS Act 2006’).

1.2 The five NCL CCGs are:

NHS Barnet CCG;

NHS Camden CCG;

NHS Enfield CCG;

NHS Haringey CCG; and

NHS Islington CCG. 1.3 In accordance with its statutory powers under section 13Z of the National Health

Service Act 2006 (as amended) (‘NHS Act 2006’), NHS England subsequently delegated the exercise of the functions specified in section 4 below to each of the NCL CCGs for their own geographical areas.

1.4 Each CCG has established its own individual Primary Care Commissioning Committee

as a committee of its Governing Body. The purpose of each committee is to be a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers.

1.5 To promote cross NCL understanding, collaborative and integrated working,

information sharing, benchmarking, greater transparency, openness and help manage conflicts of interest each of the NCL CCGs have agreed to hold their Primary Care Commissioning Committee meetings in the same time, in the same place, as a committee in common with a common Terms of Reference. This committee in common is known as the NCL Primary Care Commissioning Committee (‘Committee’).

1.6 These Terms of Reference set out the membership, remit, responsibilities and

reporting arrangements of the Committee. 2. Committees in Common 2.1 The following form the Committee:

NHS Barnet CCG Primary Care Commissioning Committee;

NHS Camden CCG Primary Care Commissioning Committee;

NHS Enfield CCG Primary Care Commissioning Committee;

NHS Haringey CCG Primary Care Commissioning Committee;

NHS Islington CCG Primary Care Commissioning Committee. 3. Statutory Framework 3.1 NHS England has delegated to each of the NCL CCGs the authority to exercise the

primary care commissioning functions set out in section 4 below for their own geographical areas in accordance with section 13Z of the NHS Act 2006.

Page 113 of 131

3.2 Arrangements made under section 13Z of the NHS Act 2006 may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and each CCG.

3.3 Arrangements made under section 13Z of the NHS Act 2006 do not affect the liability

of NHS England for the exercise of its functions. However, each CCG acknowledges that in exercising its functions (including those delegated to it) it must comply with the statutory duties set out in Chapter A2 of the NHS Act 2006 including:

No. Statutory Duty Section of NHS Act 2006

1. Management of Conflicts of Interest 14O

2. Duty to promote the NHS Constitution 14P

3. Duty to exercise its functions effectively, efficiently and economically

14Q

4. Duty as to improvement in quality of services 14R

5. Duty in relation to quality of primary medical services

14S

6. Duties as to reducing inequalities 14T

7. Duty to promote the involvement of each patients 14U

8. Duty as to patient choice 14V

9. Duty as to promoting integration 14Z1

10. Public involvement and consultation 14Z2

3.4 In respect of the delegated functions from NHS England, the CCG will need to exercise

those functions in accordance with the relevant provisions of section 13 of the NHS Act 2006 including:

No. Statutory Duty Section of NHS Act 2006

1. Duty to have regard to impact on services in certain areas

13O

2. Duty as respects variation in provision of health services

13P

3.5 Each of the individual Primary Care Commissioning Committees which form the

Committee is established by their respective Governing Bodies in accordance with Schedule 1A of the NHS Act 2006.

3.6 The members of the Committee acknowledge that the Committee is subject to any

directions made by NHS England or by the Secretary of State. 4. Role of the Committee 4.1 The role of the Committee is to carry out the function relating to the commissioning of

primary medical services under section 83 of the NHS Act 2006. This includes the following:

Decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: o Decisions in relation to Enhanced Services; o Decisions in relation to Local Incentive Schemes (including the design of

such schemes) o Decisions in relation to the establishment of new GP practices (including

branch surgeries) and closure of GP practices; o Decisions about ‘discretionary’ payments;

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o Decisions about commissioning urgent care (including home visits as required) for out of area registered patients;

o The approval of practice mergers; o Planning primary medical care services in the area, including carrying out

needs assessments; o Undertaking reviews of primary medical care services; o Decisions in relation to the management of poorly performing GP practices

and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list);

o Management of delegated funds; o Premises costs directions functions; o Co-ordinating a common approach to the commissioning of primary care

services with other commissioners in NCL where appropriate; and o Such other ancillary activities that are necessary in order to exercise the

Delegated Functions. 4.2 In performing its role the Committee will exercise its management of the functions in

accordance with the Delegation and the Delegation Agreement that each CCG entered into with NHS England. The Delegation and the Delegation Agreement sit alongside these Terms of Reference.

4.3 The functions of the Committee are undertaken in the context of a desire to promote

increased co-commissioning to increase quality, efficiency, productivity, value for money and remove administrative barriers.

4.4 The Committee will have due regard to any relevant Quality and Safety issues which

may arise as agreed by Committee members. 4.5 In performing its role each Primary Care Commissioning Committee will act within the

powers delegated to it by NHS England. 4.6 Decisions made by each individual Primary Care Commissioning Committee will be

binding on NHS England as long as decisions are made within the scope of the powers delegated to it.

4.7 In performing its role Committee members will act in good faith towards each other,

work collaboratively, review evidence, share information, provide objective expert input and endeavour to reach a consensus and collective view.

5. Geographical Coverage 5.1 Each individual CCG is the decision maker and has responsibility for carrying out the

functions for their own geographical areas as set out below:

Committee Geographical Area

NHS Barnet CCG Primary Care Commissioning Committee

London Borough of Barnet

NHS Camden CCG Primary Care Commissioning Committee

London Borough of Camden

NHS Enfield CCG Primary Care Commissioning Committee

London Borough of Enfield

NHS Haringey CCG Primary Care Commissioning Committee

London Borough of Haringey

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NHS Islington CCG Primary Care Commissioning Committee

London Borough of Islington

6. No Double Delegation 6.1 The Committee operates under the principle of no double delegation. This means that

each CCG may only carry out the functions and make decisions for its own geographical area. No CCG has the power or authority to carry out the functions or make decisions for other any other CCG or its geographical area.

7. Pooling Budgets 7.1 The individual CCG Primary Care Commissioning Committees comprising the

Committee have no authority to pool budgets with each other. 7.2 Each individual CCG Primary Care Commissioning Committee is responsible for the

delegated funds in their respective geographical areas. 8. Membership 8.1 The membership of each of the individual Primary Care Commissioning Committees

will meet the requirement of their respective Constitutions. 8.2 The Committee and each of the individual Primary Care Commissioning Committees

shall have a lay and executive majority. 8.3 The Committee shall have the following non-voting attendees who will sit at non-voting

attendees in common across all five NCL Primary Care Commissioning Committees:

A Practice Nurse representative;

NHS England representative(s);

Health and Wellbeing Board representative(s);

Healthwatch Representative(s);

LMC Representative(s);

An NCL CCG Director of Quality;

Non-conflicted external clinicians. 8.4 The list of members and non-voting attendees is set out in Schedule 1. Schedule 1

does not form part of these Terms of Reference and may be amended or updated without the need to formally amend the Terms of Reference.

8.5 Committee members may nominate deputies to represent them in their absence and

make decisions on their behalf. Non-voting attendees may nominate deputies to represent them in their absence.

8.6 The Committee may call additional experts to attend meetings on a case by case basis

to inform discussion. 8.7 The Committee may invite or allow additional people to attend meetings as attendees.

Attendees may present at Committee meetings and contribute to the relevant Committee discussions but are not allowed to participate in any formal vote.

8.8 The Committee may invite or allow people to attend meetings as observers. Observers

may not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.

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9. Chair and Vice Chair of the Committee 9.1 The Chair of the Committee shall be a Lay Member from an NCL CCG. The Committee

Chair shall not be the Chair of an NCL CCG Audit Committee nor a Conflict of Interest Guardian.

9.2 The Vice Chair of the Committee shall be a Lay Member from an NCL CCG. The

Committee Vice Chair shall not be the Chair of an NCL CCG Audit Committee nor a Conflict of Interest Guardian.

10. Voting 10.1 Each individual Primary Care Commissioning Committee shall vote and make

decisions for their own geographical area only. A vote of one Primary Care Commissioning Committee will not be binding on any other Primary Care Commissioning Committee.

10.2 Each voting member of each Primary Care Commissioning Committee shall have one

vote with resolutions passing by simple majority. 10.3 Each Primary Care Commissioning Committee shall nominate a Lay Member from its

own CCG to have the casting vote. 10.4 The Chair of the Committee may not vote on any resolution other than on those

resolutions from his or her own CCG’s geographical area. 10.5 The Vice Chair of the Committee may not vote on any resolution other than on those

resolutions from his or her own CCG’s geographical area. 10.6 Where there is a pan NCL resolution each of the five individual Primary Care

Commissioning Committees must vote in favour of the resolution for it to pass. 10.7 Each individual Primary Care Commissioning Committee can only invest their own

delegated funds in their own geographic area. However, where there are new or additional funds available that are not delegated funds such as new transformation monies all decisions on how such money is invested will be treated as a pan NCL resolution.

11. Decisions 11.1 The Committee and each individual NCL Primary Care Commissioning Committee will

make decisions within the bounds of their remit. 11.2 Decisions of the Committee and each individual Primary Care Commissioning

Committee will be binding on NHS England as long as decisions are made within the scope of the powers delegated.

11.3 Due to the nature of primary care commissioning the Committee recognises that some

urgent and immediate decisions may need to be made outside of Committee meetings. Each individual NCL Primary Care Commissioning Committee may therefore delegate urgent and immediate decisions that need to be made outside of Committee timescales in accordance with clauses 11.4 – 11.5 and 11.8 below.

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11.4 Urgent decisions requiring a response within 24 hours will be made collectively by the

following people or their nominated deputies:

The relevant Chair of the CCG;

The relevant CCG Chief Operating Officer or NCL Director of Planning Performance and Primary Care;

The relevant CCG lay representative. 11.5 Immediate decisions requiring a response within 2 weeks will be made at a Committee

meeting where practicable. Where this is not practicable the following people or their nominated deputies will collectively make the decision:

The relevant Chair of the CCG;

The relevant CCG Chief Operating Officer or NCL Director of Planning Performance and Primary Care

The relevant CCG lay representative. 11.6 Due to the nature of primary care commissioning the Committee recognises that the

following non-contentious, low risk, decisions may be made outside of Committee meetings by those listed in clause 11.7 below: :

Requests to add or remove a partner;

Retirement of a partner and adding of a new partner;

Partnership changes- 24 hour retirement;

Opening of a patient list;

Increases in practice boundaries. 11.7 The following people or their nominated deputies may collectively make the non-

contentious, low risk decisions set out in clause 11.6 above:

The relevant CCG lay representative;

The relevant CCG clinician;

The NCL Director of Planning Performance and Primary Care. 11.8 Decisions made outside of Committee meetings will be reported to the Committee at

the next Committee meeting. This may be in a public or private part of the meeting depending on the nature of the business and the decision(s) made.

12. Quorum 12.1 Each individual Primary Care Commissioning Committee must have a lay and

executive majority to be quorate. The following members must also be present:

One lay representative;

One officer representative;

One clinical representative. 12.2 If the clinical representative referred to in clause 12.1 above is conflicted on a particular

item of business they will not count towards the quorum for that item of business and a non-conflicted clinician will be appointed or co-opted in their place.

12.3 If any representative is conflicted on a particular item of business they will not count

towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements.

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12.4 For the Committee to be quorate all five individual Primary Care Commissioning Committees must be quorate. If a Committee meeting is not quorate the Chair may permit the appointment or co-option of additional members if necessary.

12.5 In some very rare circumstances all clinicians may be conflicted and therefore it may

not be possible to co-opt or appoint a non-conflicted clinician to satisfy the quorum requirements. In this case the Chair may dis-apply the requirement to have a clinical representative present in clause 12.1 above and deem the meeting quorate upon the agreement of all of the lay representatives on the Committee.

13. Secretariat 13.1 The Secretariat to the Committee shall be provided by the NCL Corporate Services

Team. 14. Frequency of Meetings 14.1 The Committee shall meet bimonthly or as otherwise agreed by the Committee. 15. Notice of Meetings 15.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7

days in advance of the meeting. 15.2 The meeting shall contain the date, time and location of the meeting. 15.3 Where Committee meetings are to be held in public the date, times and location of the

meetings will be published on each CCG’s website. 16. Agendas and Circulation of Papers 16.1 Before each Committee meeting an agenda setting out the business of the meeting

will be sent to every Committee member no less than 7 days in advance of the meeting. 16.2 Before each Committee meeting the papers of the meeting will be sent to every

Committee member no less than 7 days in advance of the meeting. 16.3 If a Committee member wishes to include an item on the agenda they must notify the

Chair via the Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.

17. Minutes and Reporting 17.1 The minutes of the proceedings of a meeting shall be prepared by the Secretariat and

submitted for agreement at the following Committee meeting. 17.2 The approved minutes will be presented to the NHS England area team. They will also

be presented to each individual NCL CCG Governing Body as per their local requirements.

17.3 Each individual CCG will comply with their own Governing Body’s reporting

requirements. 18. Conflicts of Interest

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18.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed by each of the NCL CCGs together with a schedule setting out each CCG’s local variations to that policy.

18.2 Each CCG shall ensure appropriate local safeguards are in place to maintain the

integrity of the role of Conflicts of Interest Guardian. 18.3 The Committee shall have a Declarations of Interest Register that will be presented as

a standing item on the Committee’s agenda. In addition, an opportunity to declare any new or relevant declarations of interest will be listed as a standing item on the Committee’s agenda

19. Gifts and Hospitality 19.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest

Policy and NHS England statutory guidance for managing conflicts of interest. 19.2 The Committee shall have a Gifts and Hospitality Register that will be presented as a

standing item on the Committee’s agenda. In addition, an opportunity to declare any new or relevant declarations of relevant gifts and hospitality will be listed as a standing item on the Committee’s agenda

20. Meetings Held in Public 20.1 Meetings of the Committee shall be held in public unless the Committee resolves to

exclude the public from a meeting. In which case the meeting, in whole or in part, may be held in private. The Committee may also exclude non-voting attendees and observers. Meetings or parts of meetings held in public will be referred to as ‘Meeting Part 1’. Meetings or parts of meetings held in private will be referred to as ‘Meeting Part 2.’

20.2 Non-voting attendees, observers and the public may be excluded from all or part of a

meeting at the Committee’s absolute discretion whenever publicity would be prejudicial to the public interest by reason of:

The confidential nature of the business to be transacted; or

The matter is commercially sensitive or confidential; or

The matter being discussed is part of an on-going investigation; or

The matter to be discussed contains information about individual patients or other individuals which includes sensitive personal data; or

Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings is to be discussed;

Other special reason stated in the resolution and arising from the nature of that business or of the proceedings; or

Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time; or

To allow the meeting to proceed without interruption, disruption and/or general disturbance.

21. Questions from the Public and Deputations

21.1 The Committee may receive questions from the public at its absolute discretion in line

with the CCGs’ protocol for public questions which is available on the CCGs’ websites.

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21.2 The Committee may receive, at its absolute discretion, Deputations from members of

the public or interested parties to make the Committee aware of a particular concern or concerns they have.

21.3 Any Deputations should be sent to the Committee secretariat who will pass it to the

Chair and to the Lay Member for the CCG to which the Deputation relates for consideration.

21.4 Any Deputations must be received by the Committee secretariat at least three working

days before a Committee meeting is due to take place to be eligible to be heard at that Committee meeting. However, where it is not possible to comply with this deadline due to the papers of the meeting being published later or due to a public holiday the Deputations must be submitted within a reasonable time.

21.5 Any Deputations not received within this time will not be eligible to be heard at that

Committee meeting. However, on a strictly case by case basis there may be times where it would be highly beneficial to the Committee’s business to waive this requirement due to the relevance or content of the Deputations. In these circumstances the Chair acting with the relevant Lay Member may do so on a case by case basis and without setting any precedents of future or further waivers.

21.6 Any Deputations must take the form of a written request together with a statement

setting out what the Deputation is about. If any Deputation fails to set out this information it will be rejected.

21.7 Any Deputations which are not relevant to the Committee’s business will be rejected

21.8 The Chair acting with the relevant Lay Member may accept or reject any relevant and

properly completed Deputations on a strictly case by case basis at his/her absolute discretion and without setting any precedents for future or further decisions.

21.9 If a request is agreed the interested party and/or parties will be invited to a Committee

meeting where the Committee will consider the Deputation.

21.10 The Chair acting with the relevant Lay Member may decide how much time to allocate to any Deputations at his/her absolute discretion on a case by case basis and without setting any precedents for future or further decisions on time allocated for Deputations.

21.11 Nothing in this section 21 shall limit, prohibit or otherwise restrict the Committee’s

powers contained in section 8, 20 or 22 of these Terms of Reference. 21.12 Where the Deputation relates to business to be decided by the Chair’s own CCG’s

geographical area only the requirement for the Chair to act with another Lay Member as set out in sections 21.3, 21.5, 21.8 and 21.10 does not apply.

221. Confidentiality 221.1 Members of the Committee shall respect the confidentiality requirements set out in

these Terms of Reference unless separate confidentiality requirements are set out for the Committee in which event these shall be observed.

221.2 Committee meetings may in whole or in part be held in private as per section 20 above.

Any papers relating to these agenda items will be excluded from the public domain. For any meeting or any part of a meeting held in private all members and/or attendees

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must treat the contents of the meeting and any relevant papers as strictly private and confidential.

221.3 Decisions of the Committee will be published by Committee members except where

matters under consideration or when decisions have been made in private and so excluded from the public domain in accordance with section 20 above.

232. Standards of Business Conduct 232.1 Committee members, attendees and/or observers must maintain the highest standards

of personal conduct and in this regard must comply with:

The law of England and Wales;

The NHS Constitution;

The Nolan Principles;

The standards of behaviour set out in each NCL CCG Constitution;

Any additional regulations or codes of practice relevant to the Committee. 243. Training and Information 243.1 It is the responsibility of each organisation referred to in section 1.2 above to ensure

that their representatives at the Committee are provided with appropriate training and information to allow them to exercise their responsibilities effectively.

254. Sub-Committees 254.1 The Committee and each individual Primary Care Commissioning Committee may not

delegate any of its powers to a committee or sub-committee but it may appoint sub-committees and/or working groups to advise and assist it in carrying out its functions.

254.2 Any sub-committees or working groups must abide by the NCL Conflicts of Interest

Policy and NHS England statutory guidance for managing conflicts of interest. 265. Review of Terms of Reference 265.1 These Terms of Reference will be reviewed from time to time, reflecting experience of

the Committee in fulfilling its functions and the wider experience of CCGs in primary care commissioning.

265.2 These Terms of Reference will be formally reviewed in April each year following the

establishment of the Committee. These Terms of Reference may be changed or amended by mutual agreement of the Committee and on being approved by each of the Governing Bodies of the NCL CCG’s in accordance with their Constitutions.

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Schedule 1 - List of Members This schedule sets out the membership, attendees, Chair and Vice Chair of each individual Primary Care Commissioning Committee and the Committee.

NHS Barnet Primary Care Commissioning Committee The voting members of the NHS Barnet Primary Care Commissioning Committee are as follows:

Position Name Title

Clinical representative Dr Murtaza Khanbhai Governing Body GP Representative

Lay representative

Mr Ian Bretman Lay Member

Officer representative Ms Colette Wood Director of Care Closer to Home

Member with casting vote

Mr Ian Bretman Lay Member

NHS Camden Primary Care Commissioning Committee The voting members of the NHS Camden Primary Care Commissioning Committee are as follows:

Position Name Title

Clinical representative Dr Kevan Ritchie Governing Body GP Representative

Lay representative Ms Glenys Thornton Lay Member

Officer representative Ms Sarah McDonnell -Davies

Director of Primary and Community Care / Deputy Chief Operating Officer

Member with casting vote Ms Glenys Thornton Lay Member

NHS Enfield Primary Care Commissioning Committee The voting members of the NHS Enfield Primary Care Commissioning Committee are as follows:

Position Name Title

Clinical representative Dr Mateen Jiwani Governing Body GP Representative

Lay representative

Ms Karen Trew Lay Member

Officer representative

Ms Deborah McBeal Director of Primary Care Commissioning / Deputy Chief Officer

Member with casting vote

Ms Karen Trew Lay Member

NHS Haringey Primary Care Commissioning Committee

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The voting members of the NHS Haringey Primary Care Commissioning Committee are as follows:

Position Name Title

Clinical representative Dr Dina Dhorajiwala Governing Body GP Representative

Lay representative Ms Cathy Herman Lay Member

Officer representative Ms Rachel Lissauer Director of Commissioning

Member with casting vote Ms Cathy Herman Lay Member for Public and Patient Engagement and CCG Vice Chair (Non-Clinical)

NHS Islington Primary Care Commissioning Committee The voting members of the NHS Islington Primary Care Commissioning Committee are as follows:

Position Name Title

Clinical representative Dr Dominic Roberts Clinical Director, GP Representative

Lay representative Ms Sorrel Brookes Lay Member

Officer representative Ms Clare Henderson Director of Commissioning

Member with casting vote Ms Sorrel Brookes Lay Member

Non-Voting Attendees The following non-voting attendees sit as non-voting attendees on all of the NCL Primary Care Co-Commissioning Committees as attendees in common:

Position Name Title

Practice Nurse representative Ms Charlotte Cooley Practice Nurse Representative

Health and Wellbeing Board representative(s)

TBC

Healthwatch representative(s) Ms Emma Whitby Chief Executive, Islington Healthwatch

LMC Representative Mr Greg Cairns Director of Primary Care Strategy

LMC Representative Dr Manish Kumar Chair, Enfield LMC

NHS England Representative Ms Anne Whateley Director Primary Care Commissioning and Transformation

NCL CCG Director of Quality Ms Neeshma Shah Director of Quality & Clinical Effectiveness, Camden CCG

External Clinician TBC TBC

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External Clinician TBC TBC

External Clinician TBC TBC

The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference. Chair and Vice of the Committee in Common The Chair and Vice Chair of the Committee are as follows:

Position Name Title CCG Geographical Area

Chair Ms Cathy Herman (from Haringey CCG)

Lay Member for Public and Patient Engagement and CCG Vice Chair (Non-Clinical)

Haringey

Vice Chair Ms Sorrel Brookes

Lay Member for Public and Patient Engagement

Islington

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Islington Clinical Commissioning Group Governing Body Meeting 11 September 2019

Report Title Revised Terms of Reference for the Islington Patient and Public Participation (PPP) Committee

Date of report 4 July 2019

Agenda Item

5.3

Lead Director /

Manager

Caroline Rowe Head of Communications and Engagement

Tel/Email Caroline.rowe3@nhs.net

GB Member Sponsor

Dr Katie Coleman Chair of Islington’s PPP Committee

Report Author

Caroline Rowe Head of Communications and Engagement

Tel/Email Caroline.rowe3@nhs.net

Name of Authorising Finance Lead

Not applicable Summary of Financial Implications

.

Report Summary

The terms of reference for the Islington CCG PPP Committee have been reviewed in light of clarification to the position of the Chair. The current PPP terms of reference say the Chair for the PPP Committee at Islington CCG should be a Governing Body member with PPP Involvement. At present that is Dr Katie Coleman, but she is the co-opted GP Representative in attendance at Governing Body Meetings. The CCG wants to retain our current position with Dr Coleman leading the PPP Committee until March 2020 and are proposing a minor change to the Terms of Reference to reflect this. Advice has been sought from Chris Hanson, Governance and Risk Lead, North Central London CCGs. He has proposed the following amendments to the terms of reference:

To change the wording in both the ‘Membership’ and ‘Chair’ sections of the terms of reference, from, ‘Governing Body member with a portfolio of PPP,’ to, ‘Clinical Lead for Patient and Public Participation.’

Recommendation The Governing Body is asked to APPROVE the revised Terms of Reference.

Identified Risks Not Applicable

Conflicts of Interest Not Applicable

Resource

Implications

Not Applicable

Engagement

The PPP Committee has inputted into the revisions of the terms of reference and includes lay representation, community members, Healthwatch, governing body members and other members of the CCG’s team.

Equality Impact

Analysis

Not Applicable

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Report History and

Key Decisions

Terms of reference approved by the PPP Committee on 4 July 2019.

Next Steps Not Applicable

Appendices

Terms of Reference for the PPP Committee

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Page 1 of 4

NHS ISLINGTON CLINICAL COMMISSIONING GROUP PATIENT & PUBLIC PARTICIPATION COMMITTEE

TERMS OF REFERENCE 1. Introduction

The Patient & Public Participation Committee (the Committee) is established, and powers are delegated to it, by the Governing Body of Islington Clinical Commissioning Group (the CCG), in accordance with the CCG’s Constitution. The Committee’s overarching purpose is to ensure that the CCG fulfils its commitment to develop and maintain relationships with our patients and the public through reviewing the processes of, and the decisions and actions taken by, the organisation. The Committee has no power to establish sub-committees. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the CCG’s Constitution.

2. Membership The Committee shall be appointed by the Governing Body as set out in the CCG’s Constitution and may include individuals who are not members of the Governing Body. The membership shall comprise:

Clinical Lead for Patient and Public Participation

Two Governing Body Elected Members

The Governing Body Lay Member with responsibility for Patient and Public Participation

Member of the Executive Management Team

Governing Body Chair (ex-officio)

Chief Operating Officer (ex-officio)

3. Chair

The Chair of the committee will be the Clinical Lead for Patient and Public Participation. .

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Page 2 of 4

When the Chair is unavailable, an elected Governing Body member or Lay Member will Chair the meeting.

4. Frequency of meetings

The Committee will normally meet a minimum of 4 times a year.

5. Quorum

A quorum shall be three members. If a meeting of the Committee is not, or ceases to be, quorate, the procedures set out in the CCG’s Constitution shall be followed.

6. Non-voting members

Meetings shall be attended by the following non-voting members:

One Local Authority representative

One Healthwatch representative

Two community members

Members of the CCG’s communications and engagement team

The length of term for community members will be two terms of three years with an option for the community member to re-apply after the two terms, if they would like to. The Chair of the Committee shall invite other individuals to attend meetings on an ad hoc basis to enable the Committee to discharge its responsibilities.

7. Secretariat support

The Islington CCG Communications and Engagement Team will be responsible for providing secretariat support to the Committee.

8. Conduct of business

The Committee shall apply best practice in its deliberations and in the decision-making processes. It will conduct its business in accordance with national guidance and relevant codes of conduct, the Constitution of the CCG, and good governance practice.

9. Remit and responsibilities of the Committee

The Committee shall:

Promote engagement with patient groups in order to involve interested patients in commissioning.

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Page 3 of 4

Oversee the development and implementation of the CCG’s Patient and Public Participation Strategy

Ensure that strategies relating to equality and diversity are embedded in the CCG’s engagement and participation structures and processes, noting that the CCG’s Quality and Performance Committee has overall responsibility for assuring the CCG’s equality and diversity strategies and practices.

Promote engagement and partnership working with voluntary and community groups to develop new or existing services.

Ensure that new or developing services commissioned by the CCG consider the patient experience.

Monitor the effectiveness of participation.

Receive assurance around the work of the CCG with other committees and groups to ensure that Patient and Public Involvement is embedded in their structure and processes.

Acknowledge that the Quality and Performance Committee has the responsibility of understanding and using patient experience as part of its fuller understanding of quality.

Receive updates on any areas of concern regarding complaints managed by the CCG.

Receive regular updates on STP engagement and ensure alignment with STP.

Share good practice on PPP across Haringey and Islington CCGs via the Communications and Engagement team which supports both CCGs.

Risk Management

The Committee shall review those risks on the corporate risk register which have been assigned to it and ensure that appropriate and effective mitigating actions are in place.

Policy Approval The Committee may approve any CCG policies falling within its remit.

10. Reporting arrangements

The Committee shall report regularly to the Governing Body by providing a copy of its minutes to each Governing Body meeting. It will also draw the attention of the Governing Body to any matters requiring disclosure to them, or requiring Governing Body approval. The Committee will receive reports relevant to its remit from any group or working group as appropriate.

11. Review of terms of reference

The membership and terms of reference shall be reviewed annually. Any proposals to change the terms of reference or membership must be approved by the Governing Body.

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Adopted: March 2014 Reviewed: November 2018

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