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Newham CCG Board Part I Meeting 2-3pm, Thursday 28 September 2017 Committee Rooms Newham CCG 4 th Floor Unex Tower, 5 Station Street, London E15 1DA 1
Newham CCG Board Part I Meeting
2-3pm, Thursday 28 September 2017 Committee Rooms Newham CCG 4th Floor Unex Tower, 5 Station Street, London E15 1DA
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Newham CCG - Acronyms List
ACRONYM MEANING
AC Audit CommitteeACC Acute Commissioning CommitteeA&E Accident & Emergency
APMS Alternative Provider Medical Services (a type of Primary care contract)AQP Any qualified providerBDG Board Development GroupBart's / BHT Barts Health NHS TrustBAF Board Assurance FrameworkBMA British Medical Association BCP Business Continuity PlanC&MCC Children & Maternity Commissioning CommitteeCCC Community Commissioning CommitteeCQC Care Quality CommissionCAG Clinical Academic group CCG Clinical Commissioning GroupCQRM Clinical Quality Review MeetingCQUINs Commissioning for Quality and Innovation (Payment Framework)CSU Commissioning Support Unit CHN Community Health Newham DirectorateCHS Community Health SystemsCPD Continuing Professional Development CCU Critical Care UnitDTOC Delayed Transfers of CareDoH Department of HealthDRSS Diabetes Retinopathy Screening ServiceDES Direct Enhanced ServiceDASL Drug and Alcohol Service in LondonELFT East London Foundation Trust
EMIS web Egton Medical Information Systems (System that records patient consults)
EPR Electronic Patient RecordEPCS Extended Primary Care ServiceEPCT Extended Primary Care TeamFOI Freedom of InformationGMC General Medical Council GMS General Medical Services (a type of Primary care contract)GP General PractitionerHoT Heads of Terms (Contract Summary)HWT HealthwatchICC Integrated Care CommitteeIMT Information Management and Technology
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Newham CCG - Acronyms List
IMCA Independent Mental Capacity AdvocateIG Information GovernanceITU Intensive Therapy Unit ITT Invitation to TenderKPI Key Performance IndicatorLD Learning DisabilityLD SAF Learning Disability Self-Assessment FrameworkLAP Local Area Partnership LAs Local AuthoritiesLCFS Local Counter Fraud SpecialistLES Local enhanced serviceLMC Local Medical Committee LAS London Ambulance ServiceLBN London Borough of NewhamMM Medicines Management MHCC Mental Health Commissioning CommitteeMPIG Minimum Practice Income GuaranteeNICE National Institute of Health and Care ExcellenceNUH Newham University HospitalNHSE NHS England NELCSU North East London Commissioning Support Unit NCCG Newham Clinical Commissioning GroupOOH Out of hoursPC Procurement CommitteePC Practice CouncilPCCC Primary Care Commissioning CommitteePALS Patient Advice and Liaison ServicePPE Patient and Public EngagementPPG Patient and Public GroupPREM Patient Reported Experience MeasurePROM Patient Reported Outcome MeasuresPMS Personal Medical Services (a type of Primary care contract)PCT Primary Care TrustsPHE Public Health EnglandQC Quality CommitteeQOF Quality Outcome Framework (Assessor Validation Reports)QIPP Quality, Innovation, Productivity and PreventionRAID Rapid Assessment Interface DischargeRAG Red, Amber, GreenRC Remuneration CommitteeRTT Referral to Treatment R&D Research & DevelopmentRLH Royal London HospitalSPR Service Program ReviewSPA Single Point of AccessTOR Terms of referenceTIC Transformation and Innovation Committee TDA Trust Development AuthorityTSCL Transforming Services Changing LivesTST Transforming Services TogetherUCWG Urgent Care Working GroupUCC Urgent Care Centre
WELC Waltham Forest, East London and City (Integrated Care Programme)
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Newham CCG - Acronyms List
Whipps X / WX Whipps Cross HospitalWTE Whole Time Equivalent
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NCCG Board Part I 2-3pm Thursday 28 September 2017 Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA
Agenda
No.
Time Item Page Action Required Owner
1. Welcome
1.1 2pm Welcome, introductions, apologies and declarations of interest
Verbal Chair
1.2 2.05pm Minutes of the meeting held 13 September • Action log
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Approval Discussion
Chair
2. Patient and public engagement
2.1 2.15pm Public questions Verbal Discussion Chair
3. Strategic items for approval or discussion
3.1 2.25pm NEL commissioning arrangements 13 Approval Chair
4. Any other business
5. Date of next meetings
11 October 2017 13:30pm – 15:30pm Committee Rooms, Unex Tower 13 December 2017 13:30pm – 15:30pm Committee Rooms, Unex Tower 14 February 2018 13:30pm – 15:30pm Committee Rooms, Unex Tower
www.newhamccg.nhs.uk 5
NHS Newham CCG Board Part I 1.30-3.30pm Wednesday 13 September 2017 Committee Rooms, 4th Floor, Unex Tower, 5 Station Street, Stratford, E15 1DA
Minutes
Present: Elected Voting Members Dr Prakash Chandra (Chair) Chair and Elected GP Representative, Newham CCG
Dr Clare Davison Elected GP Representative, Newham CCG
Dr Catherine Gaynor Elected GP Representative, Newham CCG
Dr Ambady Gopinathan Elected GP Representative, Newham CCG
Dr Nasim Joarder Elected GP Representative, Newham CCG
Dr Muhammad Naqvi Joint Deputy Chair and Elected GP Representative, Newham CCG
Dr Bapu Sathyajith Elected GP Representative, Newham CCG
Dr Rima Vaid Elected GP Representative, Newham CCG
Appointed Voting Members Steve Gilvin (not present for item 3.1) Chief Officer, Newham CCG
Ajith Lekshmanan Lay Member for Audit and Governance, Newham CCG
Grainne Siggins Executive Director – Strategic Commissioning, LBN National Policy Lead & Trustee – ADASS
Fiona Smith Registered Nurse, Newham CCG
Lei Wei Interim Chief Finance Officer, Newham CCG
Appointed Non-Voting Members: Andrea Lippett Lay Member Remuneration, Newham CCG
Dr Ashwin Shah Co-opted Member, Newham CCG
Hazel Trotter Practice Manager Representative, Newham CCG
In attendance:
Selina Douglas Deputy Chief Officer, Newham CCG
Satbinder Sanghera Director of Partnerships and Governance, Newham CCG
Chetan Vyas Director of Quality & Development, Newham CCG
Kate McFadden-Lewis (minutes) Board Secretary, Newham CCG
Ceri Jacobs Director of Transformation and Delivery: North Central and East London, NHS England (London region)
Apologies Wayne Farah Vice-Chair, Lay Member Patient & Public Engagement Newham CCG
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1. Welcome, introduction, apologies for absence and declarations of interest 1.1 The Chair welcomed the members to the meeting and with a quorum being present the meeting
was declared open. Apologies were received from Wayne Farah, Vice Chair/Lay Member –PPE, Newham CCG. S Gilvin declared an interest under item 3.1.
The Chair welcomed Ceri Jacob, Director of Transformation and Delivery: North Central and East London, NHS England (London region), who was present for the discussion on item 3.1.
The Chair welcomed L Wei; now attending in her capacity as Interim Chief Finance Officer for Newham CCG.
1.2 Minutes of the last meeting The minutes of the meeting held 14 June 2017 were accepted as an accurate record.
1.3 Action log The action log was reviewed and the following information received:
CCG155: S Douglas advised that the Newham CCG vision has now been revised to: ‘Improving health and wellbeing outcomes with and for the people of Newham, ensuring equality for all’.
CCG156: C Vyas updated that a deep dive on safeguarding training was undertaken at the last Newham site CQRM meeting. Exception reports will be provided to the QPF committee and then through the quality report to the Board to provide assurance. On this basis C Vyas recommended this action be closed.
CCG157: C Vyas stated he has discussed this with S Douglas and agreed that with the A&E improvement plan, which is on the Board agenda today and the integrated performance dashboard that will be presented to the QPF committee from October, we do not believe there is a need to develop a further framework to monitor and would recommend this action therefore be closed.
1.4 Chief Officer’s Report The Chief Officer provided an update on work undertaken by the CCG team since the last Board meeting including:
CCG rating for 2016-17 Newham CCG has been rated ‘Good’ against NHS England’s CCG Improvement and Assessment Framework (CCGIAF) for 2016-17, maintaining the rating achieved in 2015-16. This is a significant achievement for the CCG maintaining performance against the wider ranging framework.
Board performance report The existing performance report is being revised to reflect the CCG’s strategic priorities, including the development of an Accountable Care System (ACS) and aligning performance to both the new committee structure and the 2017-18 CCGIAF. The new integrated Quality and Performance Report will be presented at the 11 October Board meeting.
Accountable Care System for Newham - progress update Newham CCG has made good progress in establishing the partnership, including generating a number of specific commissioning initiatives to support this collaborative working.
Progress in the development of Commissioning Intentions 2018-19 CCG officers are developing Commissioning Intentions in line with the ACS priority areas, a number of services have been identified for re-design, across both the acute and community sector, and outline commissioning plans will be in place by the end of September.
CCG pilot status for international GP recruitment Newham, Barking and Dagenham, Havering, Redbridge and Waltham Forest have been successful in a bid to recruit 35 international GPs across the five CCGs; one of the GPFV initiatives. The bid will support recruitment, relocation, induction and refresher training, but not funding of the posts.
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Better Care Fund 2017-18 The Better Care Fund application was submitted on Monday, due to the tight timescale this was approved by Chair’s action.
The Waltham Forest and East London (WEL) Delivery System The three CCGs in WEL as well as the three provider trusts (Barts Health, ELFT and NELFT) have made considerable progress in the development of our borough-based ACS. A proposal on the governance arrangements will be discussed at the 11 October Board meeting.
Lastly, S Gilvin informed Members that Newham CCG has been nominated for the HSJ CCG of the year award.
2. Patient and public engagement 2.1 Young people’s mental health: deferred to the next meeting.
2.2 Questions from the public Jan Blake from Newham - Save Our NHS raised a number of queries in relation to item 3.1:
i. Will Newham CCG hold a public consultation on the ACS and single AO? If not, what arethe CCGs reasons for doing so?
ii. Will Board members delay their decision if they feel that they are not fully informed on thedecision to be taken on the single AO?
iii. Does the Board agree that this proposal is to contribute to the £22bn efficiency savings?iv. Does the Board agree that the NHS can be improved with fewer staff, less money and a
growing population?v. Will the Board pass these changes with no protest or concerns?
Response: S Gilvin noted that the majority of these queries will be addressed during the discussion of item 3.1. The CCG have been advised that consultation is not necessary as this does not represent a service change. However, the CCG plans to carry out stakeholder engagement on the changes. S Gilvin acknowledged that the current environment is challenging, with having to meet the control total and the growing needs of our patients. However, the move to the ACS is a key enabler of collaborative integrated working and key to integrated working with the borough.
3. Strategic items 3.1 NEL commissioning arrangements
P Chandra presented on the proposed new commissioning arrangements across North East London, delivered through the appointment of a single accountable officer and supporting governance arrangements. These arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. Discussion points included:
i. Newham CCGs proven track record for collaboration and successful partnership workingii. that although there is no formal requirement to engage on management arrangements of
CCGs across NEL, Newham CCG recognises the importance of stakeholder and publicengagement, particularly around development of the ACS, Transforming Services Togetherand the Building Healthy Communities programmes
iii. LBN concerns around the size of the STP and the capacity to design services to ensure aseamless, stable and comprehensive system for patients
iv. acknowledgement on the tight timescale, and the need to ensure a smooth transitionalperiod to the ACS / STP and new commissioning arrangements.
P Chandra informed the Board of the note received from Newham CCG’s Non-Executive Directors outlining their concerns and further asks around this proposal, including:
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i. Convene a meeting between Chairs and Lay Vice Chairs to share our decision to defer andour rationale in order to establish any areas of consensus of concerns and requirements forfuture board deliberations
ii. Ensure that common legal advice is available for boards on areas of concern identified byeach board and the above meeting
iii. Ensure the next Newham Board report provides a full business case that specificallyidentifies, quantifies, and evidences the financial and outcome benefits of the proposal andhow it will secure these benefits more effectively than current arrangements, e.g. Why anSAO will be better able to secure system wide change that 7 strong CCG chairs and AO’s
iv. Clearly articulates how we will apply the learning from previous local collaborations thathave not yet been successful, including the Bart’s Health and BHR CCG collaboration and astrategy for risk mitigation
v. Ensure the next Newham board report:a. Defines a rational for change that defines specific benefits to the people of Newham
in whose interest we have a statutory responsibility to actb. Provides a detailed job description, ways of working, duties, powers and
responsibilities of the SAOc. Sets out a transparent process for selection and remuneration of the SAOd. Shows evidence of due diligence in defining the SAO skill set and the availability and
obtainability of a suitable body of candidatese. Sets out the Terms of Reference for the proposed joint Committee or the Committee
in common, and the mechanisms of accountability to this board for both thecommittee and the SAO
f. Specifies clear evidence of the cost effectiveness of the proposal for a SAO forNewham and the system as a whole
g. Explain how the new proposal will support the development of our Borough basedACS, including evidence of systems of assurance that demonstrate that subsidiaritywould determine priorities, in addition to improving our current cross CCG working
h. Demonstrate how the proposed new arrangements will improving our current crossCCG working arrangements
i. Include a comprehensive risks register, that identifies the specific risks for Newhamj. Sets out viable recommendations for the development of alternative sector wide
collaborative commissioning arrangements for the board to considerk. The Chair and Vice Chair discuss this proposal with our Lead Councillor for Health
and Newham Healthwatch to ensure that future reports consider and reflect theirviews
vi. The lay Vice-Chair for PPE initiates a process of patient and public engagement on the SAOproposal that utilises the opportunity offered by the upcoming AGM and ensures that futurereports consider and reflect the views of local patients and communities
vii. We would like to see greater clarity on how Primary Care Commissioning will be protectedlocally
viii. How do we ensure the SAO has capacity to do this role?ix. The Local Authority need a firm commitment that there will be a local borough facing team
to support local delivery
The Board agreed to hold an extraordinary Board meeting on 28 September 2017 to receive a further report that addresses these concerns. The formal decision on this item was deferred to 28 September.
3.2 Barts Health A&E improvement plan S Douglas presented on the actions being taken to ensure that Barts Health deliver on the national target of 95% of patients attending Emergency Departments being seen within four hours, by March 2018.
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The plan focuses on four key areas: demand management, emergency department, bed occupancy and out of hospital support to discharge. The plan is being monitored through the Newham Urgent Care working Group and reporting directly to the A&E Delivery Board and Newham is currently on track to meet the target by March 2018. Discussion points included:
i. the importance of a robust plan and assurance process in place as winter approachesii. the important role of the 8-8, 7 day access to GP services over winter.
The Board noted the A&E improvement plan, and endorsed the Newham CCG approach ahead of winter.
3.3 Ivory Ward reconfiguration M Naqvi presented the report outlining the proposal to permanently move the Ivory Ward beds for older adults with functional mental health issues at Newham Centre for Mental Health, to the Mile End Hospital site, where ELFT has already located this service for patients of City and Hackney and Tower Hamlets. In discussion the Board noted:
i. the importance of continued stakeholder engagement following the move, including withpatients, staff, relatives and local residents, as well as continued monitoring of patient safety and experience
ii. the recommendation from the QPF Committee to approve this move following a detailedquality, performance and finance triangulated review of the proposal, giving assurance that the move does not negatively impact on patient quality.
It was agreed that the Board would receive an update report at the December meeting, to include the outcome of the consultation with stakeholders.
The Board approved the recommendation for the permanent move of the Ivory Ward beds to the Mile End Hospital site.
3.4 Board Assurance Framework- S Sanghera presented the current position of the BAF for 2017/18. Key points included:
i. as recommended at the last meeting, the performance and quality risks have now beenseparated
ii. a number of areas have been recommended for a deep dive review in 2017-18 as outlinedin paragraph 3.1.1 of the paper.
In discussion the Board noted the need for robust mitigations in place for each CCG are to ensure all are undertaking the necessary actions to meet the system control total for the STP. It was agreed that the governance arrangements for oversight of the STP would be included in the next BAF report.
The Board agreed the current BAF risk ratings and revisions as outlined in the report as well as the schedule for deep dive reports for 2017/18.
3.5 Quality Report F Smith presented the Quality Report to the Board, reporting on performance against the KPIs, the key exceptions and the actions taken in relation to improvement. Discussion points focussed around the two the two specific issues being looked at for Barts Health:
i. same sex accommodation breaches for Barts Health, Royal London site, relate to thetrauma unit, when patients are stepped down from being intensively managed
ii. Amber Alerts actioned within target of 10 working days – have seen an improvement, andall GPs are responded to. This improvement is a combination of fewer numbers of alerts aswell as an improvement in response time and processes in place.
S Gilvin noted the good progress that Barts Health has made since the CQC report with The Royal London Hospital, Newham University Hospital and Whipps Cross University Hospital sites each now rated Requires Improvement.
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3.6 Finance and QIPP Report L Wei presented the CCGs performance for 2017-18 and gave a progress update on planning for 2018-19.
L Wei reported a month four balanced financial position for Newham CCG, and remains on track to deliver on the CCG QIPP plans. Discussion points included:
i. the importance of ensuring robust mitigations against the potential risk of £13.5m against atotal savings target of £23.7m, such as identifying potential further savings and undertakingin depth reviews of current QIPP plans to ensure we are meeting their maximum potential
ii. the need to ensure that this message is effectively communicated to Newham CCG GPsiii. the important role of patient engagement and education in supporting these initiatives.
The Board noted Newham CCG’s financial position as at 2017/18 Month 4 and the progress on financial planning for 2018/19.
4. AOB S Gilvin congratulated Newham University Hospital on the successful and well planned Cerner Millennium upgrade over the weekend.
5. Date of next meetings • 2-3pm Thursday 28 September 2017• 1.30-3.30pm Wednesday 11 October 2017
Committee Rooms, 4th Floor Unex Tower, 5 Station Street, Stratford, E15 1DA
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Action reference
Meeting date
Minute reference Action Owner Update
CCG159 13/09/2017 3.3Update report in the Ivory Ward reconfiguration, to include the outcome of the consultation with stakeholders.
S Douglas On the agenda for December 2017 meeting.
CCG160 13/09/2017 3.4Governance arrangements for oversight of the STP control total to be included in the next BAF report.
S Sanghera
Newhan CCG Board Action Log Part I - 28/9/17
ITEM 1.3 - highlighed items represent a recommendation to remove from register
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Newham CCG Board Part I 28 September 2017
Title North East London Commissioning Arrangements
Agenda item 3.1
Author Chetan Vyas, Director of Quality and Development and Programme Lead for Phase 1 of the North East London Commissioning Arrangements Programme
Satbinder Sanghera, Director of Partnerships and Governance, Governance Workstream Lead for Phase 1 of the North East London Commissioning Arrangements Programme
Presented by Dr Prakash Chandra, Chair, NHS Newham CCG
Contact for further information
Chetan Vyas, NHS Newham CCG, Director of Quality and Development and Programme Lead for Phase 1 of the North East London Commissioning Arrangements Programme , [email protected], 02036882325
This paper is for Decision
Action required The Board are asked to: 1. Approve the recommendation to appoint a single accountable officer
for the CCGs in North East London;2. Approve the recommendation that the single accountable officer will
also act as the STP lead;3. Approve the recommendation to establish the governance
arrangements, including the joint committee and committees incommon at system level, to provide clear direction and support forthe single accountable officer, including delegated functions.
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Executive summary
Following the discussion of this item at the NHS Newham CCG Board meeting held on 13 September 2017 a number of points were raised and assurances sought from the Lay Members and other Board Members.
This paper provides a response to each of the points raised.
The original paper, also appended, asks Newham CCG Board to approve recommendations for new commissioning arrangements across North East London, delivered through the appointment of a single accountable officer and supporting governance arrangements. These arrangements are designed to reflect changes in the context for commissioning and the very high priority of building sustainable local accountable care systems. The proposals have been developed as a transitional arrangement that will evolve over time to reflect progress with the development and implementation of the local accountable care systems.
Supporting papers
Appendices • Table 1 – Response to Board points• Appendix A – Accountable Officer JD• Appendix B – Scheme of Delegation• Appendix C – 13 September Board paper
How does this fit with NHS Newham CCG strategy?
Values Working with our partners to improve health outcomes The proposals offer the 7 CCGs of North East London a stronger focus for collaborative work and efficiencies of commissioning process that will both underpin the development of local accountable care systems and secure the delivery of priorities set out in the Five Year Forward View. Aims Ensuring equity of health and wellbeing outcomes
By working together the 7 CCGs will be able to deliver efficiencies in commissioning and develop an aligned approach to working with local providers to ensure their long term sustainability and which will support the delivery of effective Accountable Care Systems. Strengthened collaborative arrangements will enable access to greater commissioning resources and free up time to build on the progress already made locally on integrated health and social care.
Where has the paper been already presented?
NHS Newham CCG Board on 13 September 2017. Discussions relating to commissioning arrangements across North East London in Board Development sessions on 10 May 2017 and 12 July 2017
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Risk The CCG priorities related to this report are as follows:
1. To lead the development of a Newham-based health and care systemwhich will bring together services in way that delivers high quality services and the best outcomes for the people of Newham.
In addition, the following enablers to ensure that Newham’s health care economy continues to be sustainable:
1. To support the local workforce to adapt to meet the needs of Newhampatients now and into the future.
2. To develop strong and future proofed hospitals in East London.
The key BAF risk this report corresponds to is:
BAF.02 – Failure to effectively meet the CCG’s financial targets and savings plans in 2017/18.
BAF.03 – Failure to implement the key programmes within the Sustainability and Transformation Plan and therefore failure to achieve the system control total.
Agreeing the recommendations of this report will assist the CCG to deliver on the above priorities and mitigate the risks by contributing to :
• Supporting the development of an Accountable Care System in theborough through establishing a framework to facilitate provider trustsparticipation in the system and implementation of a reformed paymentmechanism
• Delivering financial sustainability against a backdrop of increasingdemand. The appointment of an AO (combined with the role of STPlead) is key to securing the transfer and application of transformationfunds to North East London;
• Securing the decentralisation of the commissioning of specialisedservices through the appointment of an AO and assisting the CCG tojoin up services and improve patient outcomes.
• An aligned commissioning strategy to support long term viability of localacute providers and all local NHS organsiations
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Equality impact This document relates to all Newham residents in the 9 protected characteristics that are covered by the Equality Act 2010 and our Equality Duties. The proposals themselves will enable the development of Accountable Care Systems across North East London and will therefore potentially allow providers and commissioners to work together to develop a set of agreed outcomes to improve the health and well-being of their population and in particular target those groups that have traditionally been disadvantaged. As the Board has previously discussed the Accountable Care System provides the opportunity to address many of the challenges that our population have consistently identified as key barriers to better services such as ‘hand offs’ between providers, ‘telling my story once’ and improving the complete patient journey. These have been consistent themes identified by successive engagement exercises. The devolvement of specialised commissioning will further strengthen the ability of commissioners to join up services and address more locally the key health challenges for our population. Future specific service changes will be subject to an equalities impact assessment.
Stakeholder engagement
Discussions and engagement on commissioning arrangements across North East London have been held since the establishment of the STP within the following sessions:
• STP area CCG Chairs and Chief Officer leadership sessions – January & February 2017
• WEL CCGs joint Governing Bodies development session – 29 March 2017
The specific proposals in the report have been discussed in Newham CCG Board Development sessions on 10 May 2017 and 12 July 2017 and a joint meeting of NEL CCG Board representatives at the end of July. A report is has been presented at the Inner North East London Joint Health Overview and Scrutiny Committee on 6 September 2017 and discussions have taken place with key local stakeholders including LBN, Newham Health Collaborative and other local providers within the emerging accountable care system.
Financial Implications
It is not possible to cost the proposed changes until further work is completed on the functions that will be delegated to a north east London level and therefore the composition of local borough and shared teams. It is proposed that there is a requirement that the proposed changes will cost no more than the current management costs. Proposed costs will be set out in the Governing Body paper to the Board in November. CCGs have previously agreed a financial risk sharing arrangement in order to ensure the achievement of overall financial performance for the 7CCGs.
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Paper 3.1: NEL Commissioning Arrangements Following the NHS Newham CCG Board meeting discussions regarding the North East London Commissioning Arrangements item, the Board raised a number of points that they sought clarification/ assurances on in part 1 of the meeting. Below is the response to these points
Point Response Convene a meeting between Chairs and Lay Vice Chairs to share our decision to defer and our rationale in order to establish any areas of consensus of concerns and requirements for future board deliberations
The Chair of NHS Newham Clinical Commissioning Group (CCG) has shared the comments made at the NHS Newham CCG Board meeting held on 13 September 2017 with his Chair colleagues on 20 September 2017. CCG Chairs have had several meetings in the last three months where similar issues were discussed. However, a pragmatic approach was agreed together with a proposal for the current recommendations to be presented to each CCG Board.
Ensure that common legal advice is available for boards on areas of concern identified by each board and the above meeting.
Legal advice has been obtained on key areas of governance and further advice will be sought on areas that require clarification and for which legal advice has not already been sought.
Ensure the next Newham board report provides a full business case that specifically identifies, quantifies, and evidences the financial and outcome benefits of the proposal and how it will secure these benefits more effectively than current arrangements, e.g. Why an SAO will be better able to secure system wide change that 7 strong CCG chairs and AO’s.
Preparation of a business case option was considered but at this stage it is not possible to provide a business case to the detail required. As there are seven CCGs involved who are all taking the proposal through their governing bodies during September this work could not be completed within the timescale that would be agreed by all parties. It was therefore agreed that this work will begin and be brought back to the Board once completed.
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Further information on the case for change is set out below. The development of Accountable Care Systems in the north east London health economy is key to delivering the clinically and financially sustainable system as set out in the STP. The development of these systems will require changes to the commissioning system that will need to be addressed across north east London to support the development of the local partnerships which will actually deliver Accountable Care. The CCG Board has previously strongly endorsed the development of a borough based ACS in Newham and it has also been recognised that this will overtime significantly impact upon the role of the CCG and its commissioning functions as some current commissioning functions become part of the Accountable Care System’s responsibilities (for example Continuing Care assessments) Simultaneously NHSE has indicated that the future direction of travel for NHSE’s specialised commissioning role is to delegate these functions to CCGs providing that they have assurance of robust STP-level commissioning arrangements. This will need the focus of a single accountable officer to ensure that the governance and clinical and managerial leadership arrangements are in place.
It is therefore appropriate to consider what the allocation of commissioning functions will look like. At a NEL level, commissioning needs to evolve into commissioning the mature ACSs. Time and resource to develop ACSs at a greater pace needs to be unlocked through being more efficient and in practice this will mean undertaking certain functions once across the 7 CCGs. This includes how CCGs account for performance and assurance to the NHSE on critical performance, change and transformation issues, including the delivery of the FYFV priorities. This will provide the assurance that NHSE seeks to delegate specialised commissioning and to assure the CCG’s ACS arrangements.
Additional resources can become available to NE London if CCGs can take on, together, the commissioning of specialised services valued currently at around £630m per year (indicative 7 borough based allocations) in association with NHSE. By working effectively together, having one Accountable Officer (AO) and a robust governance structure, CCGs can also access funds for transformation. Our share of the Strategic
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Transformation Fund (STF) rises annually to £136m by 2020.
It is clear that appointing one AO, combined with their role as STP lead, is a precondition for transfer and then application of these funds locally. Finally, NEL CCGs would like to negotiate direct access to Health Education England funding for decision making locally on key areas of workforce development that fit with priorities for ACS development and service change. A separate funding of £800m is allocate for STP development – is attached to this. Newham would get an appropriate and allocated share of this new funding.
In summary the appointment of a single AO as opposed to the current 5 COs in North East London is necessary to:
• Secure NHSE assurance for the implementation of the Newham ACS • Systems to deliver cost effective and outcome led improvement in care
pathways and service delivery across systems, for example diabetes and renal care in WEL.
• Formalise and maximise the potential of the joint arrangements that take place already as a system in North East London – e.g. Transforming Care, Workforce
• Provide services and functions that should be commissioned once rather than 7 times will lead to reduction in commissioning costs including CSU costs and improve efficiency, releasing resources to the local development of the ACS
• Securing locally £630m per annum specialised commissioning services that can then align with the borough ACS
• Securing transformation funding from NHSE of £136m per annum for the benefit of our residents
• Support the process of transition from the current tariff-based payment system for acute services to a capitation based payment system to support Accountable Care
• Assure systems in place to prevent any marginalisation or loss to Newham.
Clearly articulates how we will apply the learning from previous local collaborations that have not yet been
Learning from previous experience is that proactive local engagement with site leadership both managerial and clinical has yielded better outcomes which is necessary
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successful, including the Barts Health and BHR CCG collaboration and a strategy for risk mitigation.
for ACS. Thus will enable the local commissioning team to concentrate on building and strengthening the ACS and local delivery in the interests of the Newham population.
Ensure the next Newham board report: - Defines a rationale for change that defines
specific benefits to the people of Newham in whose interest we have a statutory responsibility to act
An outline of the rationale for change has been set out in the section on page 2 and 3 above. In addition the next report will need to set out how local success will be defined and measured, for example:
• Timeline for delivery of ACS • Creation of a larger risk pool to cover the risks • Development of ACS and services closer to home would improve the patient
journey and satisfaction and is likely to release resources to be invested in workforce development.
- Provides a detailed job description, ways of working, duties, powers and responsibilities of the SAO
A detailed job description has been developed based on national templates. This job description outlines the responsibilities the successful candidate will have in undertaking their duties as a CCG Chief Officer role and as the Convenor of the STP role.
- Sets out a transparent process for selection and remuneration of the SAO
There will be a transparent recruitment process in place which has been agreed by the Chairs of the NEL CCGs. The Chairs have agreed a process to include psychometric testing, stakeholder events and an interview (with the membership of the panel also agreed and being clinically led.) The remuneration of the Single Accountable Officer will be determined by the CCG Remuneration Committees in Common meeting which is being scheduled for early October 2017
- Shows evidence of due diligence in defining the SAO skill set and the availability and obtainability of a suitable body of candidates
The competencies and skillset as outlined in the Single Accountable Officer Job Description are derived from national templates. The job description with payment terms and conditions (which will be determined by the CCG Remuneration Committees in Common) will determine the interest of possible candidates. The overall recruitment process as outlined above will ultimately determine the suitability of candidates.
- Sets out the Terms of Reference for the proposed joint Committee or the Committee in common, and the mechanisms of accountability to this board for both the committee and the SAO
The functions of the Joint Committee as currently proposed will be:
• the commissioning of specialist services • the strategic development of primary care including management of
contracting function • the commissioning of services common to all such London Ambulance
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Service (LAS) and services outside the scope of the ACSs • the agreement of acute services strategy including a common approach to
payment • workforce development • development of the framework for commissioning of local ACSs • first line of communication for NHSE on critical areas of system performance
and change and the delivery of the FYFV priorities
It is proposed that stage 2 of the process will set out in detail the terms of reference of the Joint Committee and likewise the Committee in Common that will operate at the WEL level system.
- Specifies clear evidence of the cost effectiveness of the proposal for a single AO for Newham and the system as a whole
The above points illustrate that for commissioning the financial benefits attached. In addition streamlining commissioning functions will accrue financial benefits and that will include a review of CSU functions and budgets. This will need to be quantified by the December Board Meeting if the September 28th meeting agrees to the appointment of a Single Accountable Officer and the appointment of a Joint Committee and the December Board agrees the appropriate level for future commissioning functions.
- Explain how the new proposal will support the development of our Borough based ACS, including evidence of systems of assurance that demonstrate that subsidiarity would determine priorities, in addition to improving our current cross CCG working
As set out previously it should be specified that the Newham ACS arrangements will require approval by NHSE prior to full implementation. The appointment of a single AO is part of a system wide change with the objective of enabling the local implementation of ACS. Finally, there are some major issues for hospital providers that require collective attention and action. CCGs are committed to ensuring the long term viability of Barts Health, BHRUT and the Homerton but can only do this by working together to agree the overall shape of services, develop an aligned commissioning strategy for each of the provider Trusts which supports the delivery of the ACSs and most importantly how to move to new payment arrangements away from payment by results (PbR) to ensure that hospital partners can play their full part within local ACSs. Failure to address these issues collectively will lead to instability of services locally with the risk of inequity across the NE London system. The current arrangements do not effectively secure focus, attention and follow through on those things which are better done at a north east London level. The appointment of one Accountable Officer will provide leadership and focus on those
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things which are done collaboratively and in ensuring that the big changes required to support local ACS effectiveness are delivered. Some of the strategic issues for acute services need to be addressed by the 7 CCGs together whilst others will be more appropriately progressed at a system (BHR, WEL and City and Hackney) or at Borough level.
- Demonstrate how the proposed new arrangements will improving our current cross CCG working arrangements
The proposed arrangements in part set out collaborative commissioning arrangements for the 7 CCGs for functions that currently sit with NHSE. Local commissioning arrangements will be an improvement as they will allow far greater clinical and local input across the whole pathway from primary to tertiary care. In terms of the other functions they will enable:
• the strategic development of primary care across North East London • the commissioning of services common to all such London Ambulance
Service (LAS) and services outside the scope of the ACSs once across North East London
• the agreement and delivery of an acute services strategy and a revised approach to payment
• more effective workforce development • development of the framework for commissioning of local ACSs • first line of communication for NHSE on critical areas of system performance
and change and the delivery of the FYFV
- Include a comprehensive risks register, that identifies the specific risks for Newham
A more detailed risk register will be developed but the key risks currently identified are: Ability to make decisions locally – Mitigation: CCG Board remains Statutory body; functions of single AO are very specific, Development of ACS Key relationships with Member Practices & LBN – Mitigation: Continuing development of Newham Health Collaborative; Development of ACS; Collaborative Commissioning with LBN Centralisation of resources – Mitigation: Specified functions of SAO; ACS implementation; Better Care Fund
- Sets out viable recommendations for the development of alternative sector wide collaborative commissioning arrangements for the board to consider
The alternative option is essentially the status quo, whereby there is collaborative commissioning for Barts Health and aspects of Mental Health with Tower Hamlets and City & Hackney.
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There has to be a recognition of the additional demand and pressure on the health system in north east London due to the significantly increasing population with increasing diversity and mobility. The alternative options that could potentially have been explored include the appointment of two Accountable Officers for the WELC and BHR systems or a Joint Accountable Officer. Whilst these options could potentially have been explored further it is acknowledged the report recommends a single AO for the 7 CCGs.
- The Chair and Vice Chair discuss this proposal with our Lead Councillor for Health and Newham Healthwatch to ensure that future reports consider and reflect their views.
The comments from Councillor Furness and Healthwatch Newham will be requested and incorporated.
The lay Vice-Chair for PPE initiates a process of patient and public engagement on the SAO proposal that utilises the opportunity offered by the upcoming AGM and ensures that future reports consider and reflect the views of local patients and communities
The engagement since the last Board meeting has been as follows: - Meeting with key groups such as Save our NHS Campaign, Healthwatch, 38
degrees, Intelligent Health, West Ham Foundation on At the AGM we asked for independent volunteers to join an ongoing focus group convened by our PPE Provider (Intelligent Health) to feedback to us at all stages of this process which will be over a period of time
We would like to see greater clarity on how Primary Care Commissioning will be protected locally
The delegation of primary care commissioning to CCGs across North East London has been to the Primary Care Commissioning Committees that were established and are now part of CCG constitutions. These arrangements will remain with only contracting and improvement support being managed at a NEL level under these arrangements. Any change would only take place if the CCG Board chose to do so and with the approval of member practices.
How do we ensure the SAO has capacity to do this role?
The paper that was discussed at the NHS Newham CCG Board meeting on 13 September 2017 outlined that the Single Accountable Officer will lead a team comprised of the Borough/System leaders and Corporate Directors, including a “lead” Chief Finance Officer, acting together to provide executive lead for the NEL commissioning system. Through this structure the Single Accountable Officer will have capacity to undertake their role. The paper adds that It is proposed that work should be undertaken to define the borough and shared teams over the next few weeks with a further paper presented to November Governing Body meetings
The Local Authority need a firm commitment that there will be a local borough facing team to support local delivery
The NHS Newham CCG Governing Body have previously agreed that one of its priorities for 2017/2018 is to lead the development of a Newham-based health and care system which will bring together services in way that delivers high quality services and
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the best outcomes for the people of Newham. A strong borough-based team will be needed to support the delivery of the Newham Accountable Care System. Furthermore, NHS Newham CCG is still a statutory organisation that retains its statutory functions and it will need officers to undertake these functions.
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AccountaOfficer – Nor th Eas t London Cl i n ica l Com m iss ion i ng Gr oups
Accountable Officer – North East London Clinical Commissioning Groups
Grade: Very Senior Manager (VSM)
Reports To: Chair of NEL CCGs’ Commissioning Committee
Accountable To: Chairs of the Governing Bodies for the CCGs within the collaboration
Base: To be agreed but with a requirement to be regularly present at CCG sites within the collaboration
Hours: Full time
Context
North East London CCGs have been successful in delivering strong clinical commissioning in collaboration with our patients and in developing strong relationships with providers and partner local authorities to jointly plan services which deliver improvements for our diverse and growing populations.
We have recognised that there are a number of areas where strong leadership is needed to coordinate our collective work to achieve our ambitions as quickly as possible but in a way that adds value to the efforts at a local level to support the move to Accountable Care Systems.
The NEL CCGs are therefore looking to appoint a single Accountable Officer to support the work of the 7 statutory bodies and also act as convener for the NEL Sustainability and Transformation Partnership. The successful candidate will be the Accountable Officer for all seven CCGs supporting them to discharge their statutory responsibilities at the same time as working at scale, to ensure that outcomes are improved, the FYFV is delivered and that NEL moves rapidly towards Accountable Care Systems.
The following local organisations within North East London are working together as the East London Health and Care Partnership to deliver the North East London STP’s plan
Clinical Commissioning Groups: Barking & Dagenham; City & Hackney; Havering; Newham; Redbridge; Tower
Hamlets and Waltham Forest
Local Authorities: Barking & Dagenham; Corporation of the City of London; Hackney; Havering; Newham; Redbridge; Tower Hamlets and Waltham Forest
Providers: Barking, Havering and Redbridge University Hospitals Trust; Barts Health NHS Trust; East London NHS Foundation Trust; Homerton University Hospitals NHS Foundation Trust; NELFT NHS Foundation Trust
NHS England, Health Education England and UCL Partners are also supporting the NEL partnership.
Paper 3.1 Appendix A
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The role The job description is split into 3 elements
• The statutory role of CCG Accountable Officer (section 1) • The role as convenor of the NEL STP (section 2) • The local operating model across the NEL CCGs (section 3) The attributes and skills for each element of the role are outlined in the person specification
MAIN DUTIES AND RESPONSIBILITIES
SECTION 1 - ACCOUNTABLE OFFICER TO EACH CCG The Accountable Officer is responsible for ensuring that each CCG complies with
• its obligations under section 14Q of the NHS Act 2006 (duty on CCGs to exercise their functions effectively, efficiently and economically);
• its obligations under section 14R of the NHS Act 2006 (duty as to improvement in quality of services); • its financial duties under sections 223H – 223J of the NHS Act 2006; • its duties in relation to accounts and audit, the provision of financial information to NHSE and the
provision of information required by the Secretary of State under paragraphs 17 -19 of Schedule 1A of the NHS Act 2006; and
• any other provisions of the NHS Act 2006 as specified in guidance published by the NHSE.
The Accountable Officer is responsible for ensuring that the CCG fulfils its duties to exercise its functions effectively, efficiently and economically thus ensuring improvement in the quality of services and the health of the local population whilst maintaining value for money. The Accountable Officer will, at all times, ensure that the regularity and propriety of expenditure is discharged, and that arrangements are put in place to ensure that good practice (as identified through such agencies as the Audit Commission and the National Audit Office) is embodied and that safeguarding of funds is ensured through effective financial and management systems. The Accountable Officer, working closely with the Chair of each of the Governing Bodies, will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisation‘s ongoing capability and capacity to meet its duties and responsibilities. This will include arrangements for the ongoing development of its members and staff The Accountable Officer is also responsible for ensuring that each CCG exercises its functions in a way which provides good value for money It is for the Chief Executive of NHS England, as the Accounting Officer for that organisation, to confirm the appointment to the role of CCG Accountable Officer. This does not create an employment relationship between the AO and NHS England. NHS England will have a role in the performance management of the AO and have the authority to remove AO status in the event of significant concerns. The individual who undertakes the AO role is required to be a member of the CCG’s Governing Bodies and therefore needs to meet the core requirements for Governing Body members and work within the constitution for each CCG. Regulations also provide that some individuals are not eligible to be appointed to CCG Governing Bodies. These are summarised on the final page. Full details are detailed in schedules four (which deals with lay membership) and five of The National Health Service (Clinical commissioning groups) Regulations 2012.5 The effect of the provisions of Schedule Five is that MPs, Local Authority Councillors and employees or members of organisations that support the CCG in delivery of services are amongst those precluded from being members of the governing body. This includes any NHS England employee as well as Commissioning Support Unit (CSUs) employees. As the AO must be a member of the CCG’s governing body none of the individuals listed above can therefore be the AO. The AO may not also hold the position of Chair of the Governing Body, nor be the CFO AO appointments must also take account of the Professional Standards Authority standards for members of NHS boards and CCG Governing Bodies in England.
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SECTION 2 - CONVENOR OF THE STP From 1 April 2017, all NHS organisations are expected formally to be part of a Sustainability and Transformation Partnership (STP). These partnerships lead the development of the initial proposals developed in October 2016 into agreed plans for improving urgent and emergency care, cancer, mental health and cancer services whilst managing within a shared financial control total. These plans must now be updated in light of the two year operational plans that have now been agreed, as well as local engagement with NHS staff, patients and communities. They should also reflect key national milestones set out in Next Steps on the NHS Five Year Forward View published in March 2017. STP leaders will be at the heart of the NHS transition towards a system based on collaboration, with commissioners, providers and local government working together to improve services. STP leaders will be responsible for convening these systems, developing the governance required to make effective decisions, directing STP resources and – most importantly – driving the rapid implementation of key service improvements. The key responsibilities are Convening a Sustainability and Transformation Partnership composed of local NHS organisations, including primary care, local government and other public services. STP leaders will normally chair the STP—except where an independent chair is in place—with an STP board from constituent organisations and including appropriate non-executive partnership. An early task will be to improve collective governance, ensuring that decision-making is effective and responsive enough whilst remaining consistent with the individual statutory accountabilities of their constituent bodies. In some cases, this may include working with accountable care systems operating as part of a wider STP. These systems will be directly accountable to their populations and to the national bodies for improving services within their share of the NHS resources, but they will also be expected to play a part in the STP in order to collaborate on issues that cross boundaries. Overseeing improvements in priority services as set out in Next Steps on the NHS FYFV with a focus on: • Improving A&E performance and upgrading the wider urgent and emergency care system so as to manage
demand growth and improve patient flow in partnership with local authority social care services. • Strengthening access to high quality GP services and primary care, which are the largest point of interaction
that patients have with the NHS each year. • Improvements in cancer and mental health - common conditions which between them will affect most people
over the course of their lives. • STPs are vehicles for collaborating across traditional divides to improve these and other services. Managing within the funding available for their populations as defined by shared system control totals across commissioners and NHS providers, together with relevant local government budgets for the wider health and care system. Although this does not in any way supplant the financial accountabilities of constituent organisations, a successful STP must facilitate financial sustainability and enable organisations to achieve greater efficiencies together than they could separately. Leading conversations with patients, staff and local communities and involving them in STP plans. STP leaders will need to engage a very diverse set of stakeholders from service users, to staff, the voluntary sector, local government, elected members and MPs, and others. Providing overall strategic leadership for the STP charting a locally specific course for ameliorating health, improving care and managing the available share of the NHS budget. This includes updating the initial STP proposals put forward in October 2016 in light of the 2017/18 – 2018/19 contracting and operational planning round and translating these plans into local implementation plans with clear accountabilities for delivering local goals and the key national milestones set out in Next Steps on the NHS Five Year Forward View. This strategic leadership role may also include developing the STP towards an ‘accountable care system’—systems in which NHS organisations (commissioners and providers), in partnership with local authorities, choose to take on collective responsibility for resources and population health. Managing and engaging the network of wider organisations that contribute to the delivery of NHS services, including the academic sector, voluntary/charitable/social enterprise sector, and independent sector. Ensure the STP has necessary programme management and implementation capability. Most of this capability will be drawn from constituent organisations. However, NHS England will also deploy its own local staff under the direction of the STP where appropriate. This may also include aligning CCG management teams or governing bodies with the STP. Working with the national leadership bodies. At the same time as convening local action, STP leads will be the key point of contact for the national bodies, particularly NHS Improvement and NHS England, which will exercise their powers in consultation with STP leads where this will facilitate improvement. The national bodies will also regularly work with STP leaders on how to evolve the national architecture to better support local progress, for example, by simplifying regulatory relationships.
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SECTION 3 - LOCAL OPERATING MODEL ACROSS THE NEL CCGs
The NEL AO will take responsibility for supporting the delivery of the following areas as it is agreed that these need strategic leadership across the NEL footprint given:-
o The ambition to create ACSs which will require coordination of a significant change programme. o The ambitions outlined in our STP to improve services and improve patient outcomes. o The financial challenges in NEL o The need for scale to better deliver our plans through the commissioning system.
To provide leadership for reaching collective agreement on how to transform the health and care system across North East London as SRO for the STP and to ensure the execution of these plans through the commissioning system To support the development and implementation of an aligned NEL wide commissioning strategy which reduces system costs and implements new models of care in conjunction with the clinicians and patients in each local system To ensure there are robust local commissioning plans across the CCGs and in each system which will ensure the delivery of the FYFV priorities (mental health, urgent care, cancer, primary care) across the NEL footprint and that NEL can provide a single line of reporting against these to NHSE and other partners. To ensure that there is a commissioning strategy in place within each system to reduce unwarranted variations between the providers and CCGs who make up the NEL footprint and ensure that the individual commissioning plans of the systems don’t lead to inequalities across the NEL footprint (this is of particular importance given the patient flows into NEL providers). To ensure the effective management of the delegated commissioning functions from NHS England relating to Primary Care, ensuring effective systems are in place within each system to manage the delegation and ensure objectives are met. To establish arrangements for and lead the implementation of an operating model for the commissioning of specialised services for NEL as NHS England develops delegated and/or joint arrangements. To ensure that the work on provider collaboration and productivity is implemented through commissioning arrangements across NEL To provide leadership to the agreed NEL STP touchpoints, (beyond the FYFV priorities) of workforce, prevention, maternity, medicines optimisation, learning disabilities, ensuring that there are system wide plans to address these underpinned by robust commissioning arrangements in each of the systems. To support the coordinated introduction of payment reform across NEL in conjunction with local systems To ensure that robust plans are developed for any new monies available to NEL, that the plans have partner support and will achieve improved outcomes and STP ambitions and that there are commissioning arrangements in place to ensure the outcomes are achieved. To ensure that there is transparency and openness across the CCGs in how all funds are deployed recognising that the CCGs remain the statutory organisations. As CCGs remain statutory bodies with a financial allocation to be used for the benefit of their resident populations, the only way that money can be "moved" across the system is if CCGs agree that this would deliver benefit for their patients and is transacted via a collective risk share agreement. Therefore to be responsible for the development agreement and operation of the agreed risk share so as to ensure good governance and strategic benefit by developing and presenting proposals, ensuring there is agreement on what any funding from the risk share is used to commission, ensuring the plan is transacted via contractual arrangements, ensuring delivery and system impact is achieved and that performance is regularly monitored and reported back to the CCGs. To support the CCGs and local teams in the transition to the end state of ACSs which are each responsible for delivering the outcomes and improvements agreed by the constituent CCGs and local authorities to achieve the STP. The work to put this in place rests firmly with the leaders in each ACS but as the ACSs develop there will be a particular key leadership role for the NEL AO to develop and implement a coordinated plan and change programme across NEL focusing on the functions which will need to be done once in an aligned way including the strategic commissioning of the ACS’s and to link with national ACS development work to bring learning back to NEL
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To establish the performance management system for NEL and ensuring local commissioning plans are in place to deliver national and local performance targets, that appropriate remedial action is taken as required and taking responsibility for assurance and performance management to NHS England on behalf of NEL To ensure that the strategic direction and vision for the CCGs agreed by the Governing Bodies is kept under regular review and support them and the local teams to ensure that their agreed plans are effectively delivered. To work with the CCG chairs to ensure that the CCGs fulfill their statutory obligations whilst working on a larger footprint and ensure that the CCGs exercise their functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCGs‘ constitutions as agreed by their members. To manage the NEL senior managers (NEL Executive and local Borough roles) and support them to be an effective team enabling them to work with patients and clinicians to deliver the CCGs strategic and operational plans and in doing so build the necessary capacity and capability across the managerial and clinical leadership team. To enhance and enshrine a culture that ensures the voices of member practices of the CCGs continue to be heard and that the voice of patients and clinicians is at the heart of decision making. To ensure that the values of the individual CCGs are reflected in new leadership arrangements and in how the CCG duties are exercised. To ensure all governance is effectively managed across the CCGs in line with the terms and requirements outlined within CCG constitutions, NHS England and statutory guidance and the Nolan principles. To ensure the highest standards of practice in the management and development of all staff. To work closely with the Chairs of the Governing Bodies to ensure that individual GB members and all those in leadership positions exercise proper constitutional and governance the ongoing capability and capacity of the organisations to meet their duties and responsibilities and the changing landscape. To ensure the CCGs operate in a way that maintains high standards of public service, public accountability and probity. To ensure that the CCGs, when exercising their functions, act with a view to ensuring health services are provided in a way which promoted the NHS constitution and the NHS Mandate from NHS England. To ensure that the CCGs value diversity and promote equality and inclusivity in all aspects of their business. Initial priorities The NEL AO will be reliant on good local leadership arrangements at each ACS/CCG who can:
o Lead integrated commissioning with local authorities as the critical lever to take forward the ACS and improve outcomes.
o Work closely with local patients and clinicians to continue to deliver local patient benefits and co-design solutions.
o Lead local partnership relationships. o Ensure robust financial management and governance. o Support the transition to an ACS model and associated local organisational development activities o Work with and support the CCG governing bodies.
An early priority for the AO is to develop an operating model to discharge this in with the CCG Chairs, GBs, and local partners by the NEL AO. Objectives for the local roles will be agreed between the CCG Chairs and the NEL AO. Similarly the AO will need to develop proposals with the CCG Chairs and GBs for discharge of financial responsibilities and for other collective responsibilities Management Arrangements Although the Accountable Officer will be employed by one CCG, there will be a memorandum of understanding outlining the relationship between the host employer and all the other CCGs to ensure that requirements of all the CCGs are met. As part of this objectives and performance management systems will be developed with the post holder to reflect the objectives of individual governing bodies and their oversight by the individual chairs.
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Person Specification
SPECIFIC ATTRIBUTES AND COMPETENCIES REQUIRED AS ACCOUNTABLE OFFICER (from the national AO job description)
o demonstrable ability to exercise sound judgement; o the ability to understand the limits of his or her management competencies and the wisdom to seek advice
when these are reached; o an understanding of corporate governance as a key element of integrated governance and of the
responsibilities that the accountable officer role needs to ensure these are discharged to a high standard; o the capability to secure the full range of management expertise, through their senior team, to ensure that
the day-to-day management of all aspects of the CCG‘s business can be discharged. o an understanding of the role of the accountable officer in setting and developing the culture of the
organisation and leading the wider organisational development in the context of engagement with key stakeholders;
o the ability to oversee the development of an organisational vision and values for the organisation; o a basic understanding of current legal requirements and good practice in employment practices, equality
and discrimination; o financially literate with the ability to review critically, challenge and effectively utilise financial information,
including financial statements for decision-making; o an understanding of the principles of value for money and an ability to challenge performance on this basis; o an understanding of the requirements of effective financial governance and probity; o a broad understanding of the NHS financial regime and an ability to develop capability within the CCG to
enable interpretation of relevant legislation and accountability frameworks; o an ability to understand the CCG‘s risk environment including knowledge and understanding of the
strategies that have been adopted by the CCG and the risks inherent in any transformation strategies; o good understanding of the role of effective communications and engagement with patients, public,
workforce and stakeholders in achieving/delivering CCG objectives and maintaining the reputation of the NHS and CCG;
o ability to develop a clear and compelling organisational narrative that describes the future strategy of the CCG, and to communicate this narrative and progress to a wide range of audiences; and
o ability to communicate complex clinical issues in laypersons language at public meetings and through media interviews.
Specific further leadership quality
o Setting direction - effective leadership requires individuals to contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values.
Specific understanding and skills
o sound understanding of good governance; o in-depth understanding of health and care, and an appreciation of the broad social, political and economic
trends influencing them; o capability to understand and analyse complex issues, drawing on the breadth of data that needs to inform
CCG deliberations and decision-making; and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions;
o has the confidence to question information and explanations supplied by others, who may be experts in their field;
o has the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill;
o has the ability to take an objective view, seeing issues from all perspectives and especially external and user perspectives;
o strong skills in recognising key influencers and the capability to engage them effectively in the CCG‘s business;
o excellent interpersonal and communication skills, and experience in engaging GPs and other health and care professionals, alongside patients in commissioning that improves quality and secures value for money; and
o sufficient understanding of NHS finance and other key organisational issues, such as HR and risk management, to discharge the overall responsibilities of accountable officer.
CORE ATTRIBUTES AND COMPETENCIES REQUIRED AS A MEMBER OF THE GOVERNING BODY Each individual needs to:
o demonstrate commitment to continuously improving outcomes, tackling health inequalities and delivering the best value for money for the taxpayer;
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o embrace effective governance, accountability and stewardship of public money and demonstrate an understanding of the principles of good scrutiny;
o demonstrate commitment to clinical commissioning, the CCG and to the wider interests of the health services;
o be committed to ensuring that the governing body remains in tune with the member practices; o bring a sound understanding of, and a commitment to upholding, the NHS principles and values as set out
in the NHS Constitution; o demonstrate a commitment to upholding The Nolan Principles of Public Life along with an ability to reflect
them in his/her leadership role and the culture of the CCG; o be committed to upholding the proposed Standards for members of NHS Boards and Governing Bodies in
England developed by the Council for Healthcare Regulatory Excellence;3 o be committed to ensuring that the organisation values diversity and promotes equality and inclusivity in all
aspects of its business; o consider social care principles and promote health and social care integration where this is in the patients‘
best interest; and o bring to the governing body, the following leadership qualities:
o creating the vision - effective leadership involves contributing to the creation of a compelling vision for the future and communicating this within and across organisations;
o working with others - effective leadership requires individuals to work with others in teams and networks to commission continually improving services;
o being close to patients - this is about truly engaging and involving patients and communities; o intellectual capacity and application - able to think conceptually in order to plan flexibly for the
longer term and being continually alert to finding ways to improve; o demonstrating personal qualities - effective leadership requires individuals to draw upon their
values, strengths and abilities to commission high standards of service; and o leadership essence - can best be described as someone who demonstrates presence and engages
people by the way they communicate, behave and interact with others. Core understanding and skills Each individual will have:
o a general understanding of good governance and of the difference between governance and management; o a general understanding of health and an appreciation of the broad social, political and economic trends
influencing it; o capability to understand and analyse complex issues, drawing on the breadth of data that needs to inform
CCG deliberations and decision-making, and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions;
o the confidence to question information and explanations supplied by others, who may be experts in their field;
o the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill;
o the ability to take an objective view, seeing issues from all perspectives, especially external and user perspectives;
o the ability to recognise key influencers and the skills in engaging and involving them; o the ability to communicate effectively, listening to others and actively sharing information; and o the ability to demonstrate how your skills and abilities can actively contribute to the work of the governing
body and how this will enable you to participate effectively as a team member. Core personal experience
o previous experience of working in a collective decision-making group such as a board or committee, or high-level awareness of board-level‘ working; and
o a track record in securing or supporting improvements for patients or the wider public. PERSONAL QUALITIES REQUIRED AS STP CONVENOR
• A very senior figure with a track record of leading a major organisation. • Deep knowledge and strong relationships in the NHS and local government. • Committed to ‘system working’, partnering across organisations to deliver on key national priorities as set
out in Next Steps on the NHS Five Year Forward View and managing within the total resources available to the system to make these improvements.
• Expert facilitation and leadership skills; able to work through and with others to achieve tangible and lasting improvements to services.
• Experience of leading change in an open and inclusive way, with a natural ability to communicate with patients, communities and staff as well as to manage complex political environments.
• Values driven, with an optimistic outlook and a strong commitment to maintaining a high-quality NHS.
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OTHER REQUIREMENTS Qualifications
▪ Educated to Masters level or equivalent experience ▪ Evidence of continuing professional development
Experience
▪ Substantial senior commissioning experience ▪ Substantial experience of managing change successfully, clarifying and establishing organisational
direction ▪ Experience of inspiring and motivating teams ▪ Substantial experience of managing budgets and of planning resources within a health economy ▪ Experience of making service changes and working in an environment of accelerated and uncertain change ▪ Experience of developing both long and short term strategies across health and social care ▪ Demonstrable leadership experience sufficient to be able to command the confidence of all 7 CCGs ▪ Experience of working in collaborative and participative way to build agreement ▪ Experience of working in partnership with patients and clinicians in co-designing and implementing service
plans. ▪ Experience of building collaboration and shared leadership where the individual has no line management
responsibilities
Knowledge, Skills and Abilities
▪ Knowledge of NHS Commissioning policy including the Five Year Forward View, Sustainability and
Transformation Plans and Operating Guidance ▪ Able to think conceptually in order to plan flexibly for the longer term and continually alert to finding
solutions and collaborations to improve health services
Communication & Influencing
▪ Financially literate with the ability to critically review, challenge and effectively utilise financial information, including financial statements for decision-making
▪ High level negotiating skills - able to negotiate solutions across a range of partners who may have different perspectives
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Appointment to Governing Body Roles
Disqualification criteria Regulations provide that some individuals will not be eligible to be appointed to CCG governing bodies. Full details are included in schedule 5 of The National Health Service (Clinical Commissioning Groups) Regulations 2012. These disqualification criteria therefore apply to the CCG AO The regulations state that the following are disqualified from membership of CCG governing bodies: • MPs, MEPs, members of the London Assembly, and local councillors (and their equivalents in Scotland and
Northern Ireland);
• members including shareholders of, or partners in, or employees of commissioning support organisations; - A person who, within the period of five years immediately preceding the date of the proposed appointment, has been convicted
- in the United Kingdom of any offence,
- outside the United Kingdom of an offence which, if committed in any part of the United Kingdom, would constitute a criminal offence in that part,
and, in either case, the final outcome of the proceedings was a sentence of imprisonment (whether suspended or not) for a period of not less than three months without the option of a fine;
• a person subject to a bankruptcy restrictions order or interim order;
• a person who within the period of five years immediately preceding the date of the proposed appointment has been dismissed (other than because of redundancy), from paid employment by any of the following: the Board, a CCG, SHA, PCT, NHS Trust or Foundation Trust, a Special Health Authority, a Local Health Board, a Health Board, or Special Health Board, a Scottish NHS Trust, a Health and Social Services Board, the Care Quality Commission, the Health Protection Agency, Monitor, the Wales Centre for Health, the Common Services Agency for the Scottish Health Service, Healthcare Improvement Scotland, the Scottish Dental Practice Board, the Northern Ireland Central Services Agency for the Health and Social Services, a Regional Health and Social Care Board, the Regional Agency for Public Health and Wellbeing, the Regional Business Services Organisation, Health and Social Care trusts, Special health and social care agencies, the Patient and Client Council, and the Health and Social Care Regulation and Quality Improvement Authority.
• A healthcare professional who has been subject to an investigation or proceedings, by any regulatory body, in connection with the person‘s fitness to practise or any alleged fraud, the final outcome of which was suspension or erasure from the register (where this still stands), or a decision by the regulatory body which had the effect of preventing the person from practising the profession in question or imposing conditions, where these have not been superseded or lifted;
• a person disqualified from being a company director;
• a person who has been removed from the office of charity trustee, or removed or suspended from the control or management of a charity, on the grounds of misconduct or mismanagement.
August 2017
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Paper 3.1 Appendix B
Scheme of Delegation (Functions related to NEL Commissioning arrangements)
This Scheme of Delegation relates primarily to those functions considered as part of the North East London Commissioning arrangements and provides clarity on some of the other key issues to avoid any misunderstandings. It is not intended to be a comprehensive scheme relating to all CCG functions and responsibilities.
CCG Board Committee in Common
(System level functions)
Joint Committee
(NEL level functions)
ELHCP Board
Delivering CCG financial balance
Risk Management of delegated functions
Joint CCG risk pool System control total and sector-wide capital spend
Administer the transformation fund (STP)
Accountable Care commissioning.
Development of ACS with Committee in Common
Development of ACSs Development of ACS Framework for utilisation at local level
Produce acute strategy and reform of payment mechanism and implement across NEL
Borough implementation of the workforce strategy
Workforce strategy
Manage HEE funds
Commissioning local acute services
Commissioning local acute/mental health/ community services where there is agreement of GBs to do so at system level
Commissioning sector-wide services e.g. LAS, maternity, ITU, Mental Health Acute Beds, etc.
Approval of specialist commissioning strategy and policy (˃£1m)
Engagement with acute providers, NHSE (for specialist services) and public on service changes
Borough commissioning of Primary Care for example enhanced services
Contracting of delegated Primary Care (nb. This is an existing joint committee with NHSE to govern delegated primary care contracting)
Primary Care Development strategy
PPE for matters reserved to the Committee in Common
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Introduction and Purpose
1. The purpose of this paper is to recommend to the 7 CCG Governing Boards in North East London, new shared commissioning arrangements in the form of a shared Accountable Officer and supporting governance arrangements. These arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. The proposals are seen as a starting point that may evolve over time to reflect progress with implementation of the local accountable care systems.
2. This paper is the product of joint working across the 7 CCGs directed by CCG Chairs, meeting together as a Steering Group. The recommendations have been agreed by us and we believe that they will offer benefits in terms of a stronger focus for collaborative work and efficiencies of commissioning process that will both underpin the development of local accountable care systems and secure in year delivery of priorities set out in the Five Year Forward View.
3. This paper begins with some important context, talks about the direction of travel for local accountable care systems, before then setting out the proposals for a shared Accountable Officer and supporting governance arrangements.
Context
4. Public services have been through a decade of austerity with consequences for service users and citizens.
5. There is consensus that the public sector should work to integrate services and emphasise collaboration rather than competition, and to mitigate the effects of austerity as far as they can. The 2012 Health and Social Care Act is still the legal framework, and any changes must be compatible with statutory duties of a CCG as laid out in the Act.
6. The NHS 5 year Forward View and more recent guidance sets out the expectation of moving towards Accountable Care Systems (ACSs).
The NHS Five Year Forward View said: “The traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. Increasingly we need to manage systems – networks of care – not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does. And services need to be integrated around the patient.”
7. The East London Health and Care Partnership (ELHCP) Sustainability and Transformation Plan (STP) gives the overall strategic direction of shifting towards self-care, prevention, and care closer to home, trying to address the health and social inequalities that are marked across NEL, using Marmot principles in relation to the wider determinants of health. It attempts to show ways to improve outcomes while striving for financial balance, in the context of a large financial gap and population growth.
Paper 3.1: Appendix C North East London Commissioning Arrangements
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8. This broader approach requires strong partnership working between the NHS and others, with Local
Authorities being very key partners. Local authorities are keen to be involved and boroughs provide the main sense of place to most people. Local accountability is important to service users and citizens.
9. It is anticipated that ACS’s will evolve into entities which will hold a capitated budget, and are accountable to their local population and the commissioners for health and social care outcomes.
10. Across the STP there are many examples of strong clinical leadership, for example building local professional relationships around specific co-designed patient pathways to improve patient experience and ensure care is cost effective.
11. At the same time there is recognition of the need to enable working at scale where appropriate, with some positive early work around areas like informatics or medicines optimisation, recognising the need to standardise interface functions and some ways of working. CCGs collectively will need to operate with consistency when it comes to commissioning the local ACSs; that includes defining outcomes, framing the budgets, contracting with hospital providers, reviewing performance and evaluating the outcomes.
Accountable Care Systems
12. All areas in North East London have made substantial progress in developing Accountable Care Systems, and are clear this is the future direction.
13. All are working to develop integrated commissioning with their local authorities with pooled budgets under section 75 arrangements and the Better Care Fund, and with aligned decision making in other areas. Indeed there is a requirement to have local plans to integrate health and social care budgets by 2020.
14. In Barking, Havering and Redbridge (BHR) there is a tri-borough Integrated Commissioning Board, which has a provider and commissioner Board reporting to it. There are 10 localities working to integrate health and social care. The 3 CCGs have had a single accountable officer since their inception, and much of their governance operates ‘in common’ to enable decisions to be taken that are relevant to all 3 CCGs and on a borough basis when required.
15. In City & Hackney (C&H) there is a history of strong system collaboration and there are now 2 integrated commissioning Boards (ICBs) which meet ‘in common’, with 6 voting members, 3 drawn from the Local Authority members and 3 from the CCG’s governing body. The Transformation Board is drawn from all local providers and commissioners in health and social care, including the voluntary sector, Healthwatch and the PPI lay CCG member; this board makes recommendations to the ICBs. There are 4 system wide work-streams with aligned LA and CCG budgets covering all health and social care and these, working with the Transformation Board, are the building blocks for the local ACS and for taking forward local transformation work. There are 4 localities for the delivery of community based services.
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16. In Waltham Forest and East London (WEL), the three CCGs (Waltham Forest, Newham and Tower Hamlets) work both at borough level and collaborate across the WEL system. There is a long history of such collaboration with a joint clinical strategy group and development of the Transforming Services Together programme, as well as established joint arrangements to commission services from Barts Health. Recent work across WEL has acknowledged the need to align the ACS developmental work in each of the 3 Boroughs more closely with Barts Health’s future strategic direction and to develop a single operating framework to ensure consistency of hospital service support to the borough based ACS’s.
17. In Waltham Forest, outcome based contracts for community services have been developed. The CCG has been working with the local authority and provider partners to develop a robust approach to a locally owned and responsive Accountable Care System. The ACS is being developed in an incremental way by piloting the approach across four key areas (Community Care (Planned), Integrated Urgent Care, Leaving Hospital Pathways and End of Life Care). The work to create these 4 systems will be managed through the Better Care Together Programme Board which has representatives from WFCCG, NELFT, LA and Barts Health.
18. In Newham, the CCG has developed a very close working relationship with its partners locally and
in particular with the London Borough of Newham in pooling some of its resources. The CCG and the Borough have established joint posts in commissioning and are jointly commissioning child health services, mental health using the opportunities of the Better Care Fund to have a transparent approach to the funding of these services. The CCG has redesigned and worked collaboratively with providers to develop an MSK service which is integrated and outcome-based within a fixed budget with robust risk sharing agreements. This has provided valuable learning for the development of an ACS.
19. The CCG has also made significant progress working with local partners in developing an ACS
which will be primary care-led. The ACS will be commissioned in partnership with LBN and will involve Newham Health Collaborative, Barts Health and ELFT as core partners in the collaboration. The Building Healthy Communities programme and Primary Care Home pilot are key enablers for this. The CCG is establishing the necessary governance in place and working with providers to develop the provider partnership required for these services to go live in 2018.
20. Progress towards accountable care in Tower Hamlets has been given considerable impetus through the national Vanguard programme as one of the multi-specialist community provider sites. The vanguard, “Tower Hamlets Together”, has developed into a strong provider partnership with commissioners which will form the bedrock for Accountable Care System development. From September 2017 the THT Board have been delegated the CCGs commissioning intentions and QIPP monitoring functions, reporting into its Governing Body. The Tower Hamlets Health and Wellbeing Board, whose members include local providers and the voluntary sector, has taken on the overall leadership and governance for Tower Hamlets Together. New joint commissioning arrangements between LBTH and the CCG will report in through this Board. The CCG and Borough are currently out to recruitment for a Joint Director of Integrated Commissioning to lead a new joint team of THT commissioners. THT has also been at the forefront of work on population health, including capitation funding models and locally there are three key population health programme boards, children and young people, complex adults and mainly healthy adults that undertake much of the planning and development work underpinning the local ACS.
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Evolution of the Commissioning System
21. It is anticipated that the commissioning system will change as ACSs become established. A substantial part of the current CCG’s work, in particular, the service development and pathways work, will move into the ACS. Some CCGs already work in a wider system arrangement while others do not. In the transitional period CCGs will continue to need borough/system-based commissioning teams with senior management to ensure the development and delivery of these ACSs using local integrated commissioning levers with Local Authority partners. This will require senior management working with the CCG governing body/bodies and local partners to deliver the new system.
22. CCGs need to nurture the development of ACSs against strong and clear desired health and well-being benefits. CCG members are playing a key role within the emerging ACS’s as they develop networks of services on the ground. Many CCG members are focussing now on the delivery of new models along with local partners.
23. The development of ACS’s will take time and there is an important transition management role for CCGs. CCGs continue as statutory organisations through this period and retain both responsibility and accountability for achieving performance locally and living within allocations. A key goal for all CCGs is to secure an effective local ACS capable of delivering improved service performance, improved population outcomes and long term sustainability. The AO will develop links with national work on ACS development so that learning can be shared across NEL.
24. At a NEL level, commissioning needs to evolve into commissioning the mature ACSs. Time and resource can be unlocked through being more efficient and in practice this means undertaking certain functions once across the 7 CCGs. This includes how CCGs account for performance upwards to the NHSE on critical change and transformation issues, including the delivery of the FYFV priorities.
25. Additional resources can become available to NE London if CCGs can take on, together, the commissioning of specialised services valued currently at around £630m per year (indicative 7 borough based allocations) in association with NHSE. By working effectively together, having one Accountable Officer (AO) and a robust governance structure, CCGs can also access funds for transformation; our share of the Strategic Transformation Fund (STF) rises annually to £136m by 2020. It is clear that having one AO, combined with their role as STP lead, is a precondition for transfer and then application of these funds locally. Finally, NEL CCGs would like to negotiate direct access to Health Education England funding for decision making locally on key areas of workforce development that fit with priorities for ACS development and service change.
26. One of the key relationships is with our hospital and mental health providers since they will be integral to delivering services as part of the local ACSs. Much of the commissioning of hospital services will be part of the local ACS to ensure that local partners work effectively together to re-shape and then integrate services. The planning and delivery of this need to be locally determined.
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27. However, there are some big order issues for hospital providers that require collective attention andaction. CCGs are committed to ensuring the longer term viability of Barts Health, BHRUT and theHomerton but can only do this by working together to agree the overall shape of services, developan aligned commissioning strategy for each of the large provider Trusts which supports the deliveryof the ACSs and most importantly how to move to new payment arrangements away from paymentby results (PBR) in order to ensure that hospital partners can play their full part within the localACSs. Failure to address these issues collectively will lead to instability of services locally with therisk of inequity across the NE London system. The current arrangements do not effectively securefocus, attention and follow through on those things which are better done together. The appointmentof one Accountable Officer will provide leadership and focus on those things which are donecollaboratively and in ensuring that the big changes required to support local ACS effectiveness aredelivered. Some of the strategic issues for acute services need to be addressed by the 7 CCGstogether whilst others will be more appropriately progressed at a system (BHR, WEL and City andHackney) or at Borough level.
Role of the East London Health Care Partnership (ELHCP)
28. The partnership is established to develop and implement a collective strategic plan (the STP) toaddress the quality performance and financial challenges that are unique to the population in NELand take forward the Five Year Forward View priorities. It involves local authorities, providers,commissioners and other third parties under an independent chair. ‘Touch points’, wherecollaborative action across North East London (NEL) is beneficial, have been set up. It is likely thatdebate about population outcomes, benchmarking of data and action to share best practice andimprove quality will be an ELHCP function. The ELHCP does not have a legal status, but is theplace for debate and making collective recommendations to the commissioning system. It isproposed that the single Accountable Officer (AO) is also the lead for the ELHCP and willresponsible for ensuring that ideas can be brought to fruition through the ACSs when changes areagreed by commissioners.
The proposed New Commissioning Arrangements
29. We are proposing a change in the commissioning arrangements for NE London with two keypropositions:
a. The appointment of a shared Accountable Officer who will also take the STP lead roleb. The establishment of new shared governance arrangements to support commissioning at
NEL, system and individual borough levels
30. The Accountable Officer will be appointed by the 7 CCG governing bodies to be the AO for each ofthe CCGs but in particular to lead strengthened collaborative functions and work across the 7CCGs.
31. The functions work stream has undertaken some initial work on functionality at the 7 CCG level. Onthe basis of their work, they propose that the following are delivered collectively through a JointCommittee:• the commissioning of specialist services• the strategic development of primary care
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• the commissioning of services common to all such London Ambulance Service (LAS) andservices outside the scope of the ACSs
• the agreement of acute services strategy including the approaches to payment• workforce development• development of the framework for commissioning of local ACSs• first line of communication for NHSE on critical areas of system performance and change and
the delivery of the FYFV
32. All other areas will be undertaken at a system level or individual borough level using governancestructures such as Committees in Common and / or Section 75 Agreements where needed. Thesewill include for example:
a. Mental health and community services commissioningb. Quality and safetyc. Integrated commissioningd. Implementation of some decisions taken at a NEL level i.e. implementing and utilising the
ACS commissioning framework
33. The administration of the Strategic Transformation Fund would be led by the AO although decisionmaking on disbursement is a function of the 7CCGs working with partners as part of the STPprocess.
34. CCGs have agreed financial risk sharing in order to ensure the achievement of overall financialperformance for the 7 CCGs. An updated agreed process for how this would work is still in progressbut we anticipate that the agreed process would be managed by the AO working as part of a newdelegated governance process.
35. It is important for NHSE to have a clear and easy communication with the sector when it comes toperformance, FYFV priorities and change issues. The AO will be responsible for assuring NHSEand other partners that these issues are being gripped and that action follows with robust deliveryarrangements in each system.
36. Clearly this would be a very big job. In practice this option assumes the continuing presence ofstrong system or borough based leadership and designated staff that will continue to be responsiblefor ensuring and reporting on local day to day performance, ensuring the delivery of the plans withinthe local system, local finances and the engagement of local partners in developing the ACSs. Eachsystem where collaborative commissioning already exists, or borough where it does not, would havetheir own Senior Manager and a team focussed on local delivery. Whilst the local Manager would beaccountable to the AO they would be responsible for local delivery in conjunction with the CCGGB(s) and CCG Chair(s) with jointly agreed objectives. The single AO will be responsible for thealignment of the CCG plans and for the big system changes.
37. The AO will also be supported by a small corporate team focussed on the functions undertaken atscale and for the collaborative process on the big issues. The AO will lead a team comprised of theBorough/System leaders and Corporate Directors, including a “lead” Chief Finance Officer, acting
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together to provide executive lead for the NEL commissioning system. It is proposed that work should be undertaken to define the borough and shared teams over the next few weeks with a further paper presented to November Governing Body meetings.
38. It is important for us to emphasise that the AO is an Accountable Officer for each CCG separately. They will be members of each CCG governing body and act with each to take local responsibility for local performance. The current AOs’ responsibilities are formally set out in the CCGs’ Schemes of Delegation and a revised set of Schemes of Delegation will need to be produced to take account of the NEL AO role. This is a mechanism both for clarifying the roles and responsibilities of the AO but also for ensuring that the accountability of the AO to the CCGs governing body is clear. The AO is unable to exceed the powers delegated to them in these Schemes of Delegation which can provide CCG governing bodies with some additional assurance that the single AO will still need to work with and for CCG governing Bodies to agree strategies and priorities and implement them.
39. For those areas of collaborative work and functionality across the 7 CCGs, the AO will need a new and different kind of collective governance drawn from each CCG. This is to ensure effective decision making and oversight for those aspects of policy, change and commissioning which CCGs have delegated upwards. We wish to emphasise that joint decision making is the product of the CCG governing bodies acting together and not the responsibility of an AO and their team working in isolation as an Executive.
40. The Governance work stream has considered the options for how to achieve effective governance at this level and they suggested a joint committee. This joint committee would be responsible for the strategic functions that need to be done at NEL level as set out in point 31 of this paper. The document on Scheme of Delegation defines areas of responsibility at GB level, Committee in common, Joint Committee and ELHCP Board.
41. However, given the importance of preserving local accountability, sovereignty and the concept of subsidiarity, which are key aims for local people and local authorities, appropriate governance arrangements are required at a more local level. These will include the use of Committees in Common for functions where CCGs wish to collaborate at a system level (including the option of Governing Bodies choosing to meeting “in Common”) and Joint Committees with Local Authorities to oversee Section 75 Agreements and other agreements relating to ACS development and management. The recommended composition and terms of reference are set out in a separate working paper.
42. The AO will be a key member of the Joint Committee whose additional membership is recommended to include the 7 CCG Chairs, 7 CCG Lay members and two other clinical members (Nurse and Secondary Care Clinician). This Committee would agree the objectives and work programme for NEL collaborative work encompassed by the delegated functions. Members of the Committee are then jointly accountable for achievement of the objectives and work programme with the AO taking the lead role in securing delivery.
43. The AO will also be a key member of any committees in common that may be established by Governing Bodies to support collaborative working at a system level.
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A separate proposal setting out how the NEL Chairs and Governing Bodies will work together to appoint the AO has been developed for consideration by Chairs and Governing Bodies.
44. The AO will be line managed for administrative and HR issues by the Chair of the CCG thatemploys the AO, which will be different from the NEL CC Chair’s CCG. There will be a MOUbetween the 7 CCGs to describe how the management of the AO will be exercised and the roles ofthe individual CCGs and the Chairs. Attached at appendix one is a job description.
45. Figure one illustrates the assumptions made about functionality and governance with the followingkey assumptions:
a. Agreed delegated financial responsibility for specialist commissioning and STF monies andthis might be added to by further access to HEE spend and the risk pool.
b. Continuing local CCG financial responsibility for hospital, mental health, community andprimary care budgets.
c. Continuing local CCG and Local Authority responsibility for agreed integrated commissioningof health and social care.
Figure one
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46. These governance arrangements will need to connect effectively with joint arrangements to supportdecision making as part of the STP and those critical local governance arrangements, the localHealth and Well- Being Boards, which oversee integrated health and social care.
47. In parallel to the appointment, further work would be undertaken to confirm the areas of delegationand the precise form of governance required for collective decision making. There is likely to beneed for consultation with CCG members on delegation of powers.
48. It is proposed that work should commence now through the auspices of the existing CommissioningArrangements Steering Group to further define any new corporate positions and the local leadershiparrangements. These proposals should be presented to the October 2017 Governing Bodies forconsideration.
49. Subject to the approval by the 7 CCG governing bodies we wish to ensure that the AO is in placealong with the new governance arrangements no later than January 1st 2018 and earlier if possible.In order to achieve this the following actions will be required:
a. Confirm agreement to the STP part of the job description with NHSE/I and with localproviders
b. Advertise and select the AO; noting the interview panel needs majority CCG Chairrepresentation given their relationship with AO is critical
c. Confirm the areas for delegation and the precise form of the new Joint Committee and anysystem level Committees in Common
d. Consult CCG members on any changes required to constitutions to enable the delegation offunctions to the Joint Committee or any system level Committees in Common.
Financial cost of proposed changes
50. It is not possible to cost the proposed changes until further work is completed on the local boroughand shared teams however; there is an expectation that the proposed changes will be cost neutral.Costs will be set out in the October 2017 Governing Body paper noted above.
Summary of Benefits
51. We are asking the 7 CCG governing bodies to approve the appointment of a shared AccountableOfficer who will also lead the STP. We are also asking for the approval in principle of newgovernance arrangements, including the Joint Committee and the Committees in Common at asystem level, to provide clear direction and support for that role with delegated functions. Webelieve that these two proposals will provide the following benefits:
a. A clear focus on those critical aspects of strategic collaboration which will support the localdevelopment and operation of the emerging accountable care systems at the system andborough levels
b. Strengthened collaborative arrangements to enable access to greater commissioningresources
c. Efficiencies of commissioning process that will free up local time to build on the progressalready made locally on integrated health and social care
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d. Continued local management presence at the system and borough level to ensure localdevelopment and continued local accountability
e. Clearer lines of communication with regulators on performance and with partners for systemtransformation and sustainability.
The Governing Body is asked to approve the proposals set out in this paper.
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