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BRADFORD DISTRICT AND CRAVEN CCG BD&C CCG Governing Body - Public Tuesday 13 July 2021 13:15 – 16:05 To be held via Zoom – details to be circulated separately
AGENDA
ATTENDEES TO NOTE: the meeting may be audio-recorded to assist with minute-taking. Whether a meeting is being recorded will be confirmed at the start of the meeting by the Chair. All recordings will be destroyed after approval of the minutes to which they relate.
Page Item Lead Purpose Time Mins No 1. Welcome & Apologies James Thomas Information - note 13:15 2 Verbal Report 2. Declarations of Interest James Thomas Action - as 13:17 1 Verbal required Report
3. Questions from the public James Thomas Action - discuss 13:18 2 Verbal Report 4. Minutes of the previous meeting James Thomas Decision - approve 13:20 5 held 11 May 2021 and action log 7-17
5. Chief Officer & Clinical Chair’s Helen Hirst Information - note 13:25 15 Report James Thomas 18-27 6. Performance Reports
i) Finance Update Robert Maden Information & 13:40 15 28-39 ii) Patient Safety and Quality Michelle Turner Assurance 13:55 15 40-56 Improvement Report iii) System Recovery and Michelle Turner 14:10 20 57-80 Managing Demand 7. Auditor’s Annual Report on the Robert Maden Assurance 14:30 15 CCG’s Annual Report and Accounts for 81-95 2020/21 8. CCG Transition Arrangements Liz Allen Action - discuss 14.45 15 96-104
Comfort Break 15:00 5
9. Lung Cancer Check Programme Janet Hargreaves Decision - approve 15:05 15 105- Proposal 152 10. High Level Risk Report Catherine Smith Assurance 15:20 5 153-174 11. Commissioning Assurance Sue Baxter Decision – approve 15:25 15 175- Framework 211
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12. Review of constitution and Liz Allen/Robert Decision - approve 15:40 15 213- associated governance documents Maden/Sue 367 including SORD, SOs, SFIs & statutory Baxter/Diane committee ToR: Lawlor A&G terms of reference PCCC Terms of reference Remuneration Committee Terms of reference
Other terms of reference Finance & Performance terms of reference 13. Exception reports from Committee Bryan Millar Information & 15:55 5 Chairs David Richardson Assurance Verbal Neil Fell Report Ruby Bhatti
Items to receive and note
Page Item Lead Purpose Time Mins No 14. Audit and Governance Committee: Bryan Millar Assurance 368- 24 May and 8 June 383 15. Primary Care Commissioning Ruby Bhatti Assurance 16:00 3 384- Committee minutes: 9 March 2021 388 16. Finance and Performance Neil Fell Assurance 389-- Committee minutes: 1 April, 30 April & 407 6 May 2021 17. Quality Committee minutes: 8 April, David Richardson Assurance 408- 6 May 2021& 3 June 2021 425 18. Exclusion of the public - it is James Thomas Decision - approve 16:03 1 Verbal recommended that the following report resolution be passed: "That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest 19. Date and time of next meeting: 14 James Thomas Assurance 16:04 1 Verbal September 2021, 1.15pm – 4.15pm Report
For any queries regarding this agenda, please contact: Catherine Smith, Corporate Governance Manager, catherine.smith4@bradford.nhs.uk
We are working to make our meeting papers accessible. If you need these papers in a different format, please contact Catherine Smith on the above email address.
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Conflicts of Interests Check List for Meeting Chairs
(Appendix C of the Conflicts of Interest and Business Conduct Policy)
Meeting Chairs have responsibility for ensuring the appropriate management of conflicts of interest during the course of CCG meetings (see below for a definition and examples of ‘interests’). In particular they must ensure:
They are familiar with the contents of the Registers of Interests as pertinent to their Group or Committee. The CCG’s Registers of Interests can be accessed here: https://www.bradfordcravenccg.nhs.uk/ccg-information/publication-scheme/lists-and-registers/
They prepare for the meeting mindful of any actual or potential conflicts of interest that may arise relevant to the business of that meeting. Where conflicts of interest are known in advance, the individual concerned must not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict.
That declarations of interest are always an item on the agenda.
That the meeting is quorate and that this is recorded in the minutes.
That members are asked to declare any interests that are likely to lead to a conflict or potential conflict that could impact (or has the potential to impact) on any items on the agenda. This should be repeated again at individual item(s) where it is considered a conflict is likely to or could potentially arise.
Any declaration must be made clearly noted in the minutes both at the start of the meeting and at the relevant item. If there is any doubt as to whether or not a conflict of interest could arise, a declaration should be made and noted in the minutes.
The minutes must specify how the Chairs have decided to manage the declared interest. The appropriate course of action will depend on the particular circumstances, but could include one or more of the following:
Where the Chair has a conflict of interest, deciding that the vice Chair (or another non-conflicted member of the meeting if the vice Chair is also conflicted) should chair all or part of the meeting; Requiring the individual who has a conflict of interest (including the Chair or vice Chair if necessary) not to attend the meeting; Ensuring that the individual concerned does not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict; Requiring the individual to leave the discussion when the relevant matter(s) are being discussed and when any decisions are being taken in relation to those matter(s). In private meetings, this could include requiring the individual to leave the room and in public meetings to either leave the room or join the audience in the public gallery;
3 4 Allowing the individual to participate in some or all of the discussion when the relevant matter(s) are being discussed but requiring them to leave the meeting when any decisions are being taken in relation to those matter(s). This may be appropriate where, for example, the conflicted individual has important relevant knowledge and experience of the matter(s) under discussion, which it would be of benefit for the meeting to hear, but this will depend on the nature and extent of the interest which has been declared; Noting the interest and ensuring that all attendees are aware of the nature and extent of the interest, but allowing the individual to remain and participate in both the discussion and in any decisions. This is only likely to be the appropriate course of action where it is decided that the interest which has been declared is either immaterial or not relevant to the matter(s) under discussion. The conflicts of interest case studies include examples of material and immaterial conflicts of interest.
In making this decision the Chairs will need to consider the following points:
- the nature and materiality of the decision - the nature and materiality of the declared interest(s) - the availability of relevant expertise - as a general rule (and subject to the judgement of the Chairs), if an interest involves a financial interest or a significant non-financial interest, the individual should be asked to leave the meeting for the whole item
Any declaration arising during the course of a meeting / individual item must be minuted and action how to handle it agreed by the Chair and recorded in the minutes It is imperative that CCGs ensure complete transparency in their decision making processes through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the Chair must ensure the following information is recorded in the minutes:
Who has the interest The nature of the interest and why it gives rise to a conflict, including the magnitude of any interest The items on the agenda to which the interest relates How the conflict was agreed to be managed, and Evidence that the conflict was managed as intended (for example recording the points during the meeting when particular individuals left or returned to the meeting).
Quoracy of the meeting or for individual items must be checked if an interest is declared. If the meeting is no longer quorate (in full or for particular items) or there is insufficient relevant expertise to inform decision-making once those with conflicts of interests are excluded, the Chairs must agree how this should be managed, i.e. defer the item / meeting or refer any decisions for particular items(s) to another Committee for consideration and formal approval.
Refer to Standard Financial Instructions for Delegated Limits
Definition of Conflicts of Interest (Section 5 of the CCG Conflicts of Interest Policy)
Conflicts of interest may arise where personal interests or loyalties conflict with those of the CCG. Such conflicts may create problems such as inhibiting free discussions which could result in decisions or actions that are not in the best interests of the CCG, patients or the public and risk creating the impression that the CCG has acted improperly.
NHS England defines a conflict of interest as occurring:
“Where an individual’s ability to exercise judgement or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her own involvement in another role or relationship.
4 5 In some circumstances, it could be reasonably considered that a conflict of interest exists even when there is no actual conflict” (i.e. a perceived conflict).
The latest version of this guidance is Managing Conflicts of Interest: Revised Statutory Guidance for CCGs, June 2017. This guidance supersedes the previous version (June 2016) and has been fully aligned with the new cross-system guidance on Managing Conflicts of Interest in the NHS which was published in February 2017.
NHS England identifies four categories of conflicts of interest:
1. Financial interests: This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:
A director, including a non-executive director or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with a health or social care organisation. A shareholder (or similar ownership interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do business with a health or social care organisation. A management consultant for a provider
This could also include an individual (or their practices, in the case of GPs) being:
In secondary employment (see Section 7.2) In receipt of secondary income from a provider. In receipt of a grant from a provider. In receipt of payments (for example, Honoria, one-off payments, day allowances or travel or subsistence) from a provider. In receipt of funding from the pharmaceutical or med-tech industry as part of a joint working arrangement. In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).
2. Non-financial professional interests: This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:
An advocate for a particular group of patients; A GP with a special interest(s); A member of a particular specialist professional body (although routine GP membership of the Royal College of General Practitioners, British Medical Association or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE); A medical researcher.
3. Non-financial personal interests: This is where an individual may benefit personally in ways which are not directly linked to their professional career or do not give rise to direct financial benefit. This could include, for example, where the individual is:
A voluntary sector champion for a provider; A volunteer for a provider; A member of a voluntary sector board or has any other position of authority with a voluntary sector organisation. A member of a lobby or pressure group with an interest in health.
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4. Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision, for example:
Spouse / partner Close relatives e.g. parent, grandparent, child, grandchild or sibling; Close friend; Business partner. A declaration for a “business partner” in a GP partnership should include all relevant collective interests of the partnership and all interests of their fellow GP partners (this could be done by cross-referring to the separate declarations made by those GP partners).
Whether an interest held by another person gives rise to a conflict of interest will depend upon the nature of the relationship between that person and the individual and the role of the individual within the CCGs.
It is not possible to define all instances in which an interest may be a real or perceived conflict.
If in doubt it is better to assume the existence of a conflict of interest and declare it, rather than ignore it.
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DRAFT Minutes of the Governing Body PUBLIC Tuesday 11 May 2021, 13:15 – 16:15 Meeting held via Zoom Present: James Thomas Clinical Chair (Chair) Ruby Bhatti Lay Member for Primary Care Commissioning & Communities Louise Clarke Strategic Clinical Director of Strategy and Planning Angie Clegg Registered Nurse Neil Fell Lay Member for Finance & Performance Helen Hirst Chief Officer Robert Maden Chief Finance Officer Bryan Millar Lay Member for Audit & Governance David Richardson Lay Member for Quality Michelle Turner Strategic Director of Quality and Nursing Peter Brunskill Secondary Care Consultant
In Attendance: Liz Allen Strategic Director of Organisation Effectiveness Pam Essler Lay Chair of the Individual Funding Request Panel Vicki Wallace Interim Strategic Director, Transformation and Change Stacey Fleming Senior Governance and Resilience Manager Catherine Smith Corporate Governance Manager (minutes)
Apologies:
Ali Jan Haider Strategic Director of Keeping Well Charles Strachan Chair of CCG Council Sarah Muckle Director of Public Health, Bradford Metropolitan District Council
Members of the public: 0
1 Welcome and Apologies
James Thomas, Chair welcomed everyone to the meeting of the Governing Body of Bradford District and Craven Clinical Commissioning Group. The meeting was noted to be quorate.
2 Declarations of Interest
No declarations of interest were made against any agenda items. The record of members’ register of interests can be found at: https://www.bradfordcravenccg.nhs.uk/ccg-information/publication-scheme/lists-and-registers/
3 Questions received from the public
No questions had been received from the public ahead of the meeting.
4 Minutes of the previous meeting held 9 March 2021 and action log
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The minutes of the previous meeting held on 9 March 2021 were agreed to be a true and accurate record. The action log was reviewed and both outstanding actions were marked as complete.
RESOLVED: The Governing Body:
Approved the minutes of the public meeting of the Governing Body held on 9 March 2021.
5 Clinical Chair and Chief Officer’s Report
Helen Hirst presented the item which provided an update on the key issues, meetings and partnership activities affecting the CCG alongside references to national guidance and, where relevant, the local impact of this guidance.
Helen provided a brief update on work in the West Yorkshire and Harrogate Health and Care Partnership noting that the report summarises key points from the recent meetings of the Health and Care Partnership Board, the System Leadership Executive Group and the Joint Committee of CCGs. Helen referred to the new ICS (Integrated Care System) design and transition group which Helen and James Thomas sit on and oversees a number of workstreams including HR, ICP development and finance required as part of the ICS establishment work.
Helen highlighted the current Covid-19 position in Bradford district and Craven noting lower rates of infection, hospital admissions and deaths reported which are in line with national figures. The vaccination programme is going well however there are challenges to match up the lower age cohorts with the type of vaccine available. Helen highlighted the hard work and effort of all involved in the programme. Helen presented figures on uptake via cohorts and benchmarking data comparing local authority areas in West Yorkshire and Harrogate.
Vicki Wallace provided an update on the rollout of the vaccination programme explaining that three PCNs (Primary Care Networks) have decided not to continue with the programme following the provision of the second vaccination for cohorts 1-9 and the remaining patients will be invited to access the national booking site. Planning and allocation will be reviewed due to the changing nature of the vaccines and the decision not to offer AstraZeneca to people under 40. Vicki referred to targeted work to increase uptake such as pop-up clinics and drop-in sites in specific areas and the appointment of 145 community support workers through additional funding from the national vaccination programme to encourage uptake. Vicki acknowledged the fantastic response from primary care in the delivery of the programme.
Helen noted that the CCG is no longer in surge and escalation mode and command and control meetings have been stepped down. No specific concerns on Brexit were noted. Helen noted the summary of the Senior Leadership Team (SLT) meetings and noted that a paper on warfarin monitoring which was due to be presented to this meeting of the Governing Body will now come to the meeting on 13th July.
Peter Brunskill referred to the closure of some vaccination sites and noted the need for the vaccination programme to continue. Vicki explained that although three PCNs have decided not to continue with the programme there is enough capacity in the system to provide vaccinations due to additional facilities, such as Bradford College, and increased capacity in WACA and Modality who will be added to the national booking system. Pam Essler noted the issues with different vaccines and age groups and asked if vaccine supply is a limiting factor. Vicki explained that supply has previously been an issue, in terms of accessing Pfizer and receiving deliveries of the first and second vaccines, but it is expected that supply should not be an issue going forward.
Neil Fell queried how patients from the three PCNs that have withdrawn from the programme will access the vaccine. Vicki explained that all patients will receive an invite from the national booking service to either book online or via the telephone and receive the vaccine elsewhere. There is work with practices to promote where patients can access the vaccine on their websites and through social media.
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Ruby Bhatti queried if there is anything else that can be done within the city area to encourage uptake. Vicki explained that targeted work, such as with faith groups, community workers, pop-up sessions in mosques and the use of a vaccine bus, is ongoing and the uptake is improving. There is a focus on Central and Eastern European communities now as uptake in South East Asian communities has increased.
RESOLVED: The Governing Body:
Noted the information and assurance provided by the Clinical Chair & Chief Officer’s report.
6 Finance and Operational Plan 2021/22 i) Planning Guidance
Helen Hirst provided some key headlines from the operational planning guidance for 2021/22 which was issued by NHS England and Improvement on 25th March 2021 and sets out the priorities for the year. The first priority in the guidance focuses on the support for the health and wellbeing of staff recognising the impact of the Covid-19 pandemic on staff as well as reflecting of the impact on the NHS and the ability to recover and restore services as well as deliver the vaccination programme. There is an expectation to build on what has worked well during the pandemic to transform the delivery of services and restore services. There is also a focus on the development of health and care systems and collaborative working. The main emphasis in the health and care system is on recovery and improving access to services particularly the delayed and missing activity during the pandemic.
RESOLVED: The Governing Body:
Noted the contents of the Operational Planning Guidance for the NHS for 2021/22. l ii) Budget
Robert Maden talked through a presentation which provided members with an update on the financial plan for H1 2021/22 (the six month period from 1st April 2021 to 30th September 2021) following the recent publication of the operational planning guidance for this period. Robert added that the Finance and Performance Committee received and discussed a more detailed presentation on the CCG’s budget for H1 and related main financial risks on behalf of the Governing Body.
Robert highlighted that the financial arrangements that applied for the last six months of 2020/21 will also apply to H1 in 2021/22. Key focus in the guidance is on recovery and capacity building following the pandemic which is reflected in the funding streams. Robert explained that the WY&H (West Yorkshire and Harrogate) ICS fixed funding envelope has been rolled forward with adjustments, such as to reflect levels of growth funding, the reinstatement of the funding deduction for the local acute independent sector activity and a downward adjustment to the funding to meet Mental Health Investment Standard requirements to reflect the national view that the funding previously provided was for a 12 month period.
Robert referred to the main additional sources of funding alongside the funding envelope – nationally there is funding of £1bn available through the Elective Recovery Fund where organisational level financial baselines have been set and performance to access the funding will be assessed at an ICS level. Other funding streams are the Hospital Discharge Scheme and £0.5bn for mental health services which will be allocated at a system level - a schedule detailing the values and expectations of where it will be spent has been received. Information will follow on an additional funding stream related to community crisis response at home services. No access to the previous CCG surplus is expected.
Robert described the approach for expenditure budgets noting that there is a move towards normal planning arrangements and there has been a request to establish contingency reserves and deliver efficiency savings. The recommended expenditure budget details prescribing and continuing healthcare pressures which reflect local inflation and growth pressures. The expenditure budget for H1 includes a
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9 10 deficit of £5.5m due to an underlying deficit of £4m from 20/21 and a local assessment of cost pressures. Within the WY&H ICS financial risk management principles it has been agreed that expenditure will be managed within the resources available in the Bradford place so it is expected that the CCG together with local health organisations will manage this financial gap in H1.
In terms of risks, there is a savings shortfall of £1.45m relating to the minimum CCG planning requirement of 0.28% and an activity risk of £1m mainly due to continuing healthcare. It is expected that the contingency reserves of £2.5m will need to be used to offset these pressures. There is a review of prescribing and continuing healthcare expenditure for any savings opportunities. Another risk relates to the Elective Recovery Fund as receipt of the full funding depends on the performance of the ICS – if all places are able to achieve it then full reimbursement of ERF costs will be received (Plan assumption of £2.3m). Robert referred to financial risk mitigation including financial risk sharing across the ICS in line with the financial risk management principles agreed by organisations across the ICS and noted that these mitigations will ensure that the CCG will either achieve a financial break-even position or if financial risk in 2021/22 cannot be managed in total across the ICS, then the CCG will take a share of the overall ICS deficit position.
Michelle Turner referred to concerns around increased financial pressures in continuing healthcare and noted that the Quality Committee have overseen an internal audit of the service and following some concerns being raised a deepdive is being undertaken. Michelle also added that QIPP in terms of medicines optimisation and the importance of implementing QIPP challenges has been discussed and will be discussed further in a SLT meeting in June.
Neil Fell added that the Finance and Performance Committee recommend the approval of the budget for April 2021-September 2021 and referred to the plans for H2. Robert explained that there is work to consider what H2 will look like and a review is being undertaken to see where recurrent money can be taken out. James thanked Robert and the finance team for their work and the Finance and Performance Committee for supporting Robert for work across the place and the work with system to achieve the financial targets.
RESOLVED: The Governing Body: Noted the contents of the report and the recommendations from the Finance and Performance Committee that the operational budget for the period April 2021 to September 2021 (H1) is approved. Noted the financial risks associated with operating under the financial arrangements for H1 and the combination of mitigations in place to manage the risk. Endorsed the need to act in line with the financial principles agreed by partner organisations in the ICS to manage the overall ICS financial position, noting the significant reliance on the level of Place mitigation required. Endorsed the need to retain the current expenditure controls and in particular for new commitments to continue to be approved on an exceptions basis and in line with our local ‘Act as One’ arrangements iii) System Performance, Recovery and Access
Louise Clarke presented a paper which sets out the CCG’s current performance position and the work that is being undertaken within the Access programme to support recovery. Louise referred to key points relating to performance against some of the key national performance indicators that measure access to health services and which NHS Trusts and CCGs have to deliver as part of their operational plans.
In terms of hospital services Louise noted a trend of increasing A&E attendances and work within AFT and BTHFT to respond to the challenges and meet the four hour A&E waiting time target. There is a challenge for the acute trusts to meet the 18 week referral to treatment standard as elective activity has been impacted by Covid-19 and outpatient activity has continued to increase. The report refers to the acute trusts’ plans to increase elective activity and work across the trust and the independent sector to bring together waiting lists in order to achieve equitable access for patients. The use of the independent
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10 11 sector is being maximised to support diagnostic performance noting the work being undertaken to support endoscopy which remains the biggest challenge.
Within community services Louise highlighted a backlog of waits in the community dental service for patients with specific needs who need to be treated in an acute trust setting due to the availability of acute trust elective theatre capacity however the appointments have restarted.
In terms of mental health and learning disabilities the waiting times for the 6 week and 18 week targets have been consistently met and the recovery rate remains above the national target however increased referrals rates are putting pressure on mental health services, particularly in CAMHS, perinatal mental health and eating disorder services for children and young people. There has been success with the delivery of the Learning Disability Annual Health Checks which stands at 82% for 2020/21 noting strong clinical leadership support enabled by Dr Sara Humphrey and Vicky Donnelly. Health checks for patients with severe mental illness remains a challenge as some elements require face to face appointments.
Louise referred to the access to care programme which covers a number of different workstreams focusing on urgent care, elective care and recovery, and specific areas for service improvement. A priority for the programme in relation to recovery in Q4 was to secure capacity in the independent sector to support the acute trusts to reduce their waiting lists alongside the work to bring together waiting lists. This arrangement and discussions on future partnership in specialities across different sites will continue.
Louise referred to the current waiting list position as detailed in the report and explained that a key area of focus is to provide support and advice to people waiting for surgery in order to optimise their health and wellbeing. Louise explained that due to the need to isolate before surgery there has been an increase in Did Not Attends and communications have been developed to reassure patients that services are safe and to highlight the cost of not attending. Louise referred to a table in the report which shows comparator data for an average day in Bradford district and Craven versus a Covid-19 day which highlights the challenge in recovering services.
Louise referred to how the access to care programme is supporting recovery and includes projects to focus on people who have not accessed services as well as those on the waiting list to optimise their health. Work with the PCNs and Community Partnerships will identify people who have not accessed services during the pandemic, such as for cancer screening, to understand their concerns and develop a plan to address this. Data is available at PCN and practice level to identify elective and non-elective usage and primary care access and this will form the basis of the patient optimisation work and to understand the barriers to access.
Louise added that e-consults between consultants and GPs continue to be developed to avoid patients attending hospital where it is not necessary and the acute trusts are working on Patient Initiated Follow- Ups where patients remain in control of whether they return to the hospital for a follow-up appointment. Both areas of work will free up capacity in acute trusts. Louise referred to the system groups and committees who maintain oversight on system recovery plans and there is work to consider the role of each group and how assurance can be gained in a collaborative environment.
Pam Essler referred to fantastic work within the programme and noted that restart looks to be a key element alongside a shared decision-making process at all levels and queried if there is a way to look at a co-ordinated approach to support professionals and the public. Louise explained that this is being built into the MSK work and further co-ordination can be taken back through the access programme.
RESOLVED: THE GOVERNING BODY: Noted the current position and supported the work of the Access to Care programme
7 Performance Reports i) Finance Update
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Robert presented a report which provided information on the financial position of the CCG as at 31st March 2021 particularly the financial performance for the period from October 2020 to March 2021. Robert noted a break-even position for this period and for the 2020/21 financial year due to budget underspends which offset the additional savings target. Robert noted movement in month 12 in terms of increased pressure in personalised commissioning and mental health placements which have been offset by increased underspends in other budget areas. The auditors had not raised any concerns during the audit to date. Robert summarised that all organisations within the place and ICS achieved a planned position and there was good performance individually and collectively in 2020/21.
RESOLVED: The Governing Body:
Noted the financial position for the six month period to 31st March 2021 and the overall financial positon for the 2021/21 financial year Noted that subject to the audit of the Accounts for 2021/21, the CCG expects to meet its in- year breakeven target and its statutory financial targets ii) Patient Safety and Quality Improvement Update
Michelle Turner talked through a presentation which provided an update on patient safety and quality improvement and highlighted key messages from a number of areas. It was noted that new variants of Covid-19 have been discussed further in the Quality Committee and that the CCG continue to have an overview of support to the care sector and patients in their own homes.
Michelle referred to the overview of the system provider quality outcomes related to BTHFT, ANHSFT, BDCFT, primary care and care homes as summarised in the presentation. In terms of primary providers it was noted that the Primary Care Commissioning Committee have recommended that the Contract and Quality Assurance process, which had been suspended due to the pandemic, restarts, and the Quality Committee will maintain an overview of the position.
Michelle referred to the backlog of cases in continuing healthcare due to Covid-19 which were not cleared by April 2021 as per the trajectory – the CCG is working with NHS England to have the backlog cleared by June 2021 and the revised trajectory remains on track.
The presentation provides an update on the LeDeR (learning disability mortality review) programme where the CCG is the host service for the WY&H ICS and noted that the ICS hosted service gained permission from NHS England/Improvement to put a model in place that builds on current arrangements and themes and trends from the review will build into commissioning arrangements.
Michelle provided an update on vulnerable children noting progress with children looked after with the implementation of a new clinical model from April 2021 and progress was noted in a reduction in waits of children on the mental health acute pathway. It was noted that there is more work to do on children’s autism and the System Quality Committee will receive a further update.
Michelle referred to host commissioner responsibilities for people with learning disabilities and autism in inpatient settings by April 2021 which involves a service design enabling WY ICS oversight for host commissioner responsibilities and there is an interim arrangement in place with BDCFT to explore options for delegated host commissioner responsibilities.
Michelle referred to an update from the System Quality Committee (SQC) in terms of the key areas of focus for 2021/22 noting that the committee are keen to establish a framework for a shadow form of the future committee in terms of how the SQC can be developed to enable the CCG’s statutory duties to still be discharged as the CCG is ending and a session on assurance has been suggested. To support recovery the SQC have developed draft principles for the system programmes to consider in the delivery of the programmes such as impact assessments, quality and safety considerations.
Pam raised patient experience as a measure and requested that patient experience could be included within the draft principles for the system programmes. Michelle referred to the principle to consider the
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12 13 role of the citizens and patient voices in the programme and noted that there have been discussions on reviewing the Grassroots system and moving to a system Grassroots approach – the Quality Committee have received an update on progress. Pam said that she felt assured that it will be system wide and is keen to get feedback from patients as some cohorts have been struggling with some elements of the way of working during the pandemic.
RESOLVED: The Governing Body: Noted the information and assurance provided by the report, including key actions taken by the CCG to manage quality and safety issues and risks arising from Covid-19 and non- Covid-19 issues. Noted the substantial progress made by ‘health’ in addressing some of the concerns raised about the care of the children. Noted the increasing emphasis on place/system and collaboration to address challenges and poor outcomes together rather than on an individual basis with each provider.
8 Integrated Care Partnership Development
Vicki Wallace presented a paper which provided a high level overview of the plans for the establishment of an Integrated Care Partnership (ICP) in Bradford district and Craven in response to the publication of the white paper ‘Integration and Innovation: working together to improve health and social care for all’ which sets out the statutory duty to have an Integrated Care System (ICS). There will be a West Yorkshire ICS which will be made up of five separate ICPs that will mirror the current CCG footprints. It was noted that this fits with the direction of travel and builds on the partnership already in place in West Yorkshire but also notes the importance of place-based partnerships. An ICP Executive Board, chaired by Helen Hirst, has been established to support the formation of an ICP alongside an ICP Establishment and Development Programme to oversee key elements of work including vision and strategy; leadership and behaviours; design and delivery; and the CCG transition/close down. It was noted that the successful formation of the ICP will need to involve all existing partners and the entire partnership will need to be involved in the development and agreement of forms and functions. It was noted that a non- executive and councillor reference group is being established and there is consideration for the engagement of citizens in the development of the ICP.
RESOLVED: THE GOVERNING BODY: Received the update on the establishment and development of the ICP.
9 Sign up to update Strategic Partnering Agreement
Vicki Wallace presented the revised Strategic Partnering agreement noting that it has been in place since 2019 and has been reviewed to ensure that it continues to reflect the ways of working across the system. The key changes from the original document are set out in Appendix A and the Governing Body were asked to approve the revised SPA for sign off. There will be a further update to the SPA following the formation of the ICP.
Bryan Millar referred to the financial governance framework in annex 1 of schedule 6 (titled Financial and Risk Management Principles) and queried the CCG not being included in the diagram when all other parts of the system are visible. Action – Vicki Wallace to update the financial governance framework in annex 1 of schedule 6 (Financial and Risk Management Principles) of the SPA to include reference to the CCG
Neil Fell queried the commitment to the SPA until 31st March 2023 – Vicki explained that the SPA will be reviewed again in six months in order to ensure that it continues to reflect the ambition of partnership working. Vicki noted that the membership of the SPA can change and that Affinity have become a signatory alongside WACA, Modality and Bradford Care Association representing the rest of primary care.
RESOLVED: THE GOVERNING BODY:
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Received and approved the revised Strategic Partnering Agreement subject to ensuring that the CCG is included in the financial governance framework in annex 1 of schedule 6
10 Individual Funding Request Panel Report 2020-2021
Pam Essler presented the IFR annual report in order to provide assurance to the Governing Body that the CCG is fulfilling its statutory duties. Pam provided some context noting that the IFR deals with requests for interventions not commissioned as part of the NHS standard contract or contracts with provider partners. These requests follow the processes set out in the IFR policy to manage the requests using an equitable approach. Pam noted the membership of the panel which is supported by input from public health and noted that the paper highlights the panel’s successes in 2020/21 as well as the summary of the case load for 2020/21 and the breakdown of requests into the top ten clinical groups. The panel also provide oversight on the placements for patients with complex neuro-rehabilitation needs and there have been requests for funding for complex psychiatric cases.
There is a representative from the senior leadership team (SLT) on the panel so any issues can be escalated to SLT for further discussion. SLT have discussed a patient’s right to choose a provider that has another contract with another CCG or NHS England for the provision of a service as patients have requested adult ADHD assessments from a provider outside of the mental health contract with BDCFT. Following discussion at SLT and legal advice being sought, such requests are now being approved however there are potential risks relating to ongoing prescribing arrangements which would need to be picked up elsewhere.
Pam referred to future challenges with inequity as it has been noted by the panel that less requests are received for people in more deprived communities and uncertainty on IFR within an ICS with suggestions that there are common commissioning policies across the ICS to stop a postcode lottery. It was noted that initial discussions have taken place in the West Yorkshire Planned Care Group and the Clinical Thresholds group.
James commented on the importance of the wide range of representation on the panel that bring different insight and judgment to the decision-making process noting a future challenge on IFR within place and the ICS. Pam provided assurance that cases are dealt with fairly and that the best interest of the patient is the core element of the panel. James noted an opportunity for the panel to share ideas with the System Ethics Committee – Michelle added that the committee are considering what arrangements might be needed in the future in terms of a panel at place with interdependencies. Liz Allen added that capacity would be needed to have consistent policies across West Yorkshire and there will need to be a decision on shared policies even if they are implemented at place. David raised the glucose monitoring devices and asked if this will be implemented across West Yorkshire; Liz added that an approach was inherited from Airedale, Wharfedale and Craven CCGs – the Bradford CCGs had no requirement for this which has created an anomaly.
RESOLVED: THE GOVERNING BODY Received the annual report of the Associate Clinical Director IFR
11 High Level Risk Report
Stacey Fleming presented a paper detailing the ‘high level risks’ (those scoring 15 or more), new risks identified and risks closed during cycle 6 for 2020/21 which covered March 2021 – April 2021 The reviews for Cycle 1 2021/22 have commenced and risk owners and senior managers have been asked to review all risks in relation to the transition to the ICS/ICP.
There are four critical risks (scoring 20 or 25) open on the risk register relating to demand for mental health services, the Covid-19 pandemic, the impact of Covid-19 on care homes and increased health inequalities due to socio-economic and ethnicity factors. There were currently 17 ‘serious’ rated risks (scoring 15 or 16) open on the risk register. One risk relating to the backlog of CHC referrals had increased during the cycle and now scored 16 (making this a ‘serious’ level risk). One risk had
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14 15 decreased in score and this related to unidentified carers. The risk had reduced from 20 to 15 so it was now classed as a ‘serious’ risk. Risk 1590 (risk relating to outcomes for the population being negatively impacted) had been closed on the system as this had been superseded by risks relating to delayed access to elective care due to the additional pressures experienced in secondary care due to the pandemic and a risk relating to burnout amongst the NHS workforce.
Bryan suggested that a risk related to the transition from the CCG to the ICS is added to the risk register to reflect that there is a risk that the CCG fails to discharge its responsibilities during the transfer. Action – Liz Allen to add a risk relating to the transition from the CCG to the ICS in relation to a risk that the CCG fails to discharge its responsibilities during the transfer to the risk register
Robert referred to risk 1735 which relates to PC/VDI desktop resources regarding a new release of functionality in SystmOne which is currently a 1serious’ risk (with a risk score of 15) and suggested that the score and narrative is reviewed.
RESOLVED: THE GOVERNING BODY:
Received and noted the risk report and high level risk log
12 Exception Reports from Committee Chairs
Verbal updates were provided by Committee Chairs in order to share key messages with those present. Minutes of the most recent committee meetings had also been shared as part of meeting papers and would be noted under the ‘items to receive and note’ section of the agenda.
Audit and Governance Committee Bryan Millar, Chair of the Audit and Governance Committee, noted that the CCG’s financial position had been discussed and the committee will meet in May and June to review the CCG’s annual accounts and annual report from 2020/21 and to provide assurance to the Governing Body. The committee will also have a role in supporting the CCG transition programme so assurance can be provided to the Governing Body.
Quality Committee David Richardson, Chair of the Quality Committee, summarised that the group had discussed the transition to the ICS and the need to strengthen governance which includes the need to monitor any system quality issues during the transfer to the ICS. Updates on the CCG work on staff welfare and wellbeing were provided noting positive feedback from staff on the support available and added that other parts of the system are looking at the model. The committee received an update on a recent CQC inspection of BDCFT which received an overall rating of ‘good’ and noted that the service is safe, well- led and that staff understand and discharge their roles and treat patients with compassion and kindness.
Finance and Performance Committee Neil Fell, Chair of the Finance and Performance Committee, updated that the group has received assurance that the CCG will meet its financial obligations for 2020/21 and received an update on progress within the audit of the year-end accounts.
Primary Care Commissioning Committee Ruby Bhatti, Chair of the Primary Care Commissioning Committee, provided an update from the recent meeting noting that the committee approved proposed changes to the Contract and Quality Assurance process and approved the re-commencement of the revised of the process. The committee received the Internal Audit report noting the overall opinion of ‘Substantial’ assurance and noted the recommendations in the report.
13. Primary Care Commissioning Committee minutes: 12th January 2021
Noted.
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15 16
14. Finance and Performance Committee minutes: 4th February 2021 and 4th March 2021
Noted.
15. Quality Committee minutes: 4th February 2021 and 4th March 2021
Noted.
16 Exclusion of the Public
It was recommended that the following resolution be passed: “That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”.
RESOLVED: The Governing Body passed the resolution to exclude representatives of the press and other members of the public for the remainder of the meeting.
17. Date and Time of Next Meeting
The date and time of the next meeting is Tuesday 13 July 2021, 1.15pm – 4.15pm. VENUE: To be confirmed but likely to be a Zoom meeting held in public.
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16 17 Presented to the meeting held 13 July 2021
Governing Body: 2021/22 Action Log
Ref. Meeting Agenda Item Action Required Responsibility Due Date Comment Vicki Wallace to update the financial 9. Sign up to updated governance framework in annex 1 of Complete: Updated financial governance 1 11.05.21 Strategic Partnering schedule 6 (Financial and Risk Management Vicki Wallace Jul-21 framework with CCG included circulated to Agreement Principles) of the SPA to include reference to members via email the CCG Liz Allen to add a risk relating to the transition from the CCG to the ICS in relation Complete: Risk added to the corporate risk 2 11.05.21 11. High level risk report to a risk that the CCG fails to discharge its Liz Allen Jul-21 register responsibilities during the transfer to the risk register
17 1 18
NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 5
Name of meeting Governing Body Meeting date 13 July 2021 Helen Hirst, Chief Officer Title of report Chief Officer/Clinical Chair report Report author(s) James Thomas, Clinical Chair Lead(s) / SRO Helen Hirst Report lead(s) Helen Hirst James Thomas James Thomas
Paper summary and/or key discussion points This paper provides a brief update of the key issues, meetings and partnership activities affecting the CCG together with updates on national guidance and, where relevant, local impact of this guidance.
Appendix 1 provides a summary of the Senior Leadership Team meeting discussions and decisions.
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
This report is relevant to all strategic objectives.
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
1. The Governing Body is asked to note the information and assurance provided by the report.
Appendices (or other supporting papers)
1. Summary of Senior Leadership Team meeting discussions and decisions.
18 Page 1 of 5 19 1. West Yorkshire & Harrogate Health and Care Partnership (WY&H HCP)
At the May meeting of the System Leadership Executive Group members: Received an update on the current Covid-19 position and the key messages from WY&H System Oversight and Assurance Group meeting held in March; Received an update around Operational Planning for 21/22; Received a report on our non-surgical oncology approach, it was reported work was underway to plan for short, medium and long term support for non-surgical oncology (NSO) in West Yorkshire and Harrogate. Held a discussion around the future structure and function for our Partnership; the functions that we will need to build / strengthen in response to the legislation; the core functions we currently have to run the ICS and the functions that have been agreed to be undertaken at ICS level. Were provided with an update on the progress of the expansion and refresh of the Innovation and Improvement Programme Board priorities supported by the Yorkshire & Humber Academic Health Science Network (YHAHSN) and the next steps for the next 12 months. Supported the establishment of the WY&H Smokefree Forum and approved the next steps which included developing a proposal for a whole system approach and Smokefree model.
In June the Health and Care Partnership Board, held in public: Received an update on the focus and priorities of the WY&H Partnership work over the past three months. Received an update on the progress made on the delivery of the Tackling Health Inequalities for Black, Asian and Minority Ethnic Communities and Colleagues action plan. It was noted that as we develop a new statutory body for the ICS there is the opportunity to embed anti-discrimination criteria into future leaders’ job descriptions. Received an update on the WY&H Health Inequalities Academy achievements to date, work in progress and next steps for 2021/22. Listened to work being done by SOLACE around reducing health inequalities for refuges and asylum seekers, including the work to reduce the impact of Covid-19.
The Joint Committee of CCGs: There have been no meetings of the joint committee held since the last Governing Body
Helen and James continue to attend the ICS design and transition group chaired by Rob Webster. This group meets fortnightly and oversees a number of workstreams including HR, ICP development, finance, governance as part of the ICS establishment work. The work of the group is supported by a Chairs and Leaders Reference Group which meets monthly.
2. Business Continuity and resilience update This section of the chief officer and clinical chair report outlines the current COVID situation in Bradford district and Craven. Updates on the CCG’s arrangements for the management of surge and escalation pressures across the system, responding to the post-EU exit period and addressing internal CCG matters are also referenced.
2.1 Overview of local COVID-19 figures The CCG produces a weekly COVID-19 dashboard that is shared with health and care partners across the system to enable identification of service pressures and the impact upon recovery. The City of Bradford Metropolitan District Council (CBMDC) Public Health team also produces a twice-weekly report with details of numbers of cases, hospitalisations and outbreaks. A verbal, contemporaneous summary of the current COVID-19 position can be provided in the Governing Body meeting to include; incidence, positivity rate, number of hospitalisations and number of deaths.
2.2 COVID-19 vaccination programme roll-out The COVID-19 vaccination programme continues to roll out at pace. There are 14 vaccination sites across our footprint, including one 8 primary care network (PCN) sites, 4 community pharmacy sites, 3 community vaccination hubs and 2 mobile vaccination buses. Our district met the target of offering a vaccine to all residents in JCVI cohorts 1-9 by the 15th March 2021 and is now vaccinating anyone over the age of 18 as quickly as possible. All sites are vaccinating 2nd vaccines at 8 weeks post first vaccine for over 40 year olds and 11 weeks post first vaccine for under 40 year olds, unless the person meets the green book 19 Page 2 of 5 20 criteria for an earlier 2nd vaccination (some specific clinical criteria). All PCN sites are continuing to re-call anyone who had not attended for vaccination when offered previously or who has had a first vaccine but not attended for their 2nd vaccine in weeks 8 or 11. All vaccination sites have been opened up to walk-ins to increase vaccination uptake and provide more flexibility than just a booked appointment process. As at 24th June 2021 we have given more than 628k vaccinations of which 269k are 2nd dose vaccinations. We have therefore vaccinated over 71% of people eligible for the first vaccine and above 53% of second doses. We have completed a 6 week planner for additional activities to ensure that we meet the national target to offer a vaccine to all people over the age of 18 years by 19th July 2021. The creation of more walk in capacity will enable the vaccine to be easily accessible. A verbal update of current numbers and cohorts vaccinated can be provided in the Governing Body meeting.
2.3 Health and care silver meeting The Bradford district and Craven health and care silver command meetings continue to take place weekly and are split into two sections:
• surge and escalation pressures • COVID-19 and post-EU exit
Tactical actions are developed in response to the system service delivery requirements applicable to surge and escalation pressures, in relation to COVID-19 and the post-EU exit period. This includes ensuring that we have a co-ordinated system response to individual sector challenges as organisations respond to varying activity, staffing and other pressures. Steps are taken collectively to mitigate any risks. As the pressure from demand continues to rise in the Bradford district and Craven system the health and care silver command meeting is starting to consider what steps may be necessary to ensure maintenance of core services. Given the changing nature of these issues, a verbal update of key matters can be provided within the Governing Body meeting.
2.4 Post-EU exit period The CCG is required to report any post-EU exit related issues by exception which may impact business critical services for any of the following areas: supply of medicines, medical devices, consumables, goods and services; supply of blood products, transplant organs and tissues; workforce; estates and facilities; clinical trials; data sharing, processing and access; reciprocal healthcare and cost recovery; partner organisations that are essential to delivery of healthcare. The CCG continues to meet informally with CBMDC to ensure that any required responses in the post-EU exit period are co-ordinated.
EU citizens, who were living in the UK before the end of the Brexit transition period, need to apply to the EU Settlement Scheme before 30 June 2021. It will allow EU citizens to continue to live and work here beyond June 2021 and locks in their rights to access healthcare, benefits and other government services in the same way they currently do. The scheme has been advertised to staff, GP practices and the wider public through national and local communications. Bradford Metropolitan District Council has a number of advice and help hubs, where EU citizens and their families can go to access advice and support on Brexit and the Settlement Scheme.
2.5 CCG silver command meeting At the extended senior leadership team meeting on 9 June 2021 it was agreed that, given the only action CCG silver command was currently discussing was the safe return of staff to Scorex House and the last action logged for bronze command was in November 2020, both meetings could be stood down. Remaining actions would be transferred to SLT or ALT as appropriate and meetings will be stepped back up if required.
3. Bradford District and Craven Partnerships
3.1 Wellbeing Board (Previously Health & Wellbeing Board)
At the Wellbeing Board in June, members discussed: Employment and Skills Partnership: Building on the Economic Recovery plan through people, skills, prosperity: sustaining and supporting an inclusive economy
20 Page 3 of 5 21 for the District. The intent of the work of the employment and skills partnership is to create a more diverse workforce (by age, geography, ethnicity and disability) which is better equipped to deliver on current and future economic demands, with greater resilience, members also received the Health and Social Care Economic Partnership annual report and held a discussion around developing a public sector plan to increase diversity in senior leadership across the district over the next 5 years.
3.2 Integrated Partnership Board (ICP) Executive (Previously Health and Care Executive Board) In May members received an update from the three Health Care Partnerships: Mental Health, Learning Disabilities, and Autism; Bradford; and Airedale, Wharfedale and Craven as well as the Finance and Performance System Committee.
Ali-Jan Haider and Richard Fawcett updated members on a collaborative approach to developing a system- wide integrated commissioning roadmap for Children, young people and transitions. This is around commissioning services for children and young people, this links to the NHS children and young people transformation programme and involves the council and NHS partners. A discussion took place around our emerging integrated care partnership (ICP) strategy and Update on ICP development programme and the proposed approach to digital and data transformation.
At the latest meeting, in June members were informed that our system has been successful in securing a bid to the Health Foundation to take part in the Adopting Innovation programme. Members received an update from the joint health and care partnership board which described the continued focus on health inequalities including our work to improve autism support and services across our place. The group also received a presentation which set out Strategic Estates Outline Case for Bradford Teaching Hospitals NHS Foundation (BTHFT), whilst the case was presented on behalf of Trust, it was agreed that we will frame all future proposed estate developments as part of a wider integrated care partnership programme. The ICP Development Programme board terms of reference were approved and Sam Schwab, Head of Unit, Primary Care Networks from NHS England and NHS Improvement, joined the meeting to listen to reflections from members on how primary care networks and community partnerships are working across our place. Our feedback will help future national guidance and direction.
3.3 Strategic Coordinating Group/Outbreak Control Board The focus of the Strategic Coordinating Group meetings will be changing; the name the meetings will change to Wellbeing Executive and a new Terms of Reference will be developed. The meetings will move to monthly. The Outbreak Control Board continues to meet every two weeks and receives updates on infection, testing and vaccinations and then determines what strategic and operational actions are required.
4. Summary of Senior Leadership Team Discussions Please see attached a summary of the SLT meetings during the last two months at appendix 1
5. National Updates
5.1 ICS Design Framework and Guidance on the Employment Commitment
These two key documents which will support the transition to the new ways of working set out in the NHS white paper were published on Wednesday 16 June 2021. The West Yorkshire and Harrogate Health and Care Partnership leadership are reviewing these important documents and will provide a more detailed briefing for staff and stakeholders once they have had the opportunity to consider them. This will include our HR colleague group developing a set of questions and answers to support the local change processes. There is a commitment to retaining employment and talent within our West Yorkshire and Harrogate Health and Care Health Partnership. Links to the two documents are below. https://www.england.nhs.uk/wp-content/uploads/2021/06/B0642-ics-design-framework-june-2021.pdf https://www.england.nhs.uk/wp-content/uploads/2021/06/B0724-employment-commitment-guidance- supporting-ics-v1.pdf
Rob Webster has confirmed he is to become the full time lead for the ICS on an interim basis. Leaving his post as chief executive of South West Yorkshire Partnership Foundation Trust.
5.2 The NHS Big Tea and the Big Bradford Thank You
21 Page 4 of 5 22 The NHS Big Tea is back, and this year will be a chance for communities to come together for a national outpouring of love to thank NHS staff and each other for the huge role they have played over the last year. At 3pm on the NHS’s birthday, there’s a ‘stopping to share’ moment to express gratitude to every clinician, nurse, support worker, hospital porter and paramedic who has put themselves on the line this year to keep us and our loved ones safe.
Closer to home Bradford District is also encouraging communites to unite behind a white rose thank you campaign over the weekend of 3rd and 4th of July.
In recognition of both of these the CCG has done a formal thank you of every staff member.
5.3 Coronavirus (COVID‑19) Phase 3 restrictions remain in place, mainly due to an increase in cases of the delta variant. There is currently a 4-week pause at Step 3 of the roadmap and it is expected that England will move to phase 4 on 19 July.
For up to date guidance on all aspects of Covid-19 please visit the government website https://www.gov.uk/coronavirus
For local advice please visit the website below https://www.bradford.gov.uk/health/health-advice-and-support/coronavirus-covid-19-advice/
Your COVID recovery website has been launched to support those recovering from COVID-19 The NHS has launched a new website, ‘Your COVID Recovery’, which is aimed at supporting people who are recovering from COVID-19. It is targeted at people who have survived the virus but have persistent concerns related to areas such as breathing or mental health
For more information and to get support, visit. https://www.yourcovidrecovery.nhs.uk/
22 Page 5 of 5 23 Appendix 1
SLT updates for Governing Body: April 2021 – June 2021
14 April 2021 (Extended SLT) Strategic focus: Keeping the lights on ALT prompted a discussion around the challenges of balancing core business, transition, and close down of the CCG and the impact this would have on staff. It was acknowledged there a sense of growing anxiety amongst staff around the future and transition to an integrated care partnership (ICP) whilst supporting capacity and resilience in teams and treating all staff in a fair and equitable way in terms of development opportunities. It was agreed the narrative of close down and ‘switching the lights out’ was negative and the language should be more around the opportunities for staff to develop as part of a wider system and staff will have a future-facing roles. A number of principles were agreed to help ALT in their decision making when reviewing secondments and other vacancies.
Performance monthly update: A discussion was held around how we can provide assurance to the governing body (GB) that we are progressing with our recovery plans, as we move through the transition period and move more into a system space. It was agreed the GB should receive a performance report that includes an update from the access programme (including plans to address recovery).
BAME staff network Members of the network shared reflections since the BAME staff network was established last year. Members described how the network has encouraged staff to come together and given them a safe space to have an honest dialogue. Network members described how they have become more confident and have shared experiences; they have built on the experiences of stories shared. It was agreed it is important the work is not lost as the CCG moves through transition into the ICP.
28 April 2021 Joint, collaborative, and integrated planning and commissioning with health and social care SLT supported the proposal to create a Planning and Commissioning Forum which would reboot joint / collaborative and integrated commissioning arrangements with Bradford Council for services that improve people’s health and wellbeing. This proposal will drive integrated commissioning and create better outcomes for the population.
Strategic focus: reflection on last week's SLT/ALT development session with Paul Bennett Whilst SLT/ALT shared positive feedback and celebration of the achievements of the past 12 months, it was acknowledged there was a general level of tiredness and fatigue; this was mainly attributed to responding to Covid, recovery and continuing organisational change. It was acknowledged that this has been a challenging year and each individual’s circumstances are different, both on a personal and work level, therefore there needs to be a balance between personal responsibility and organisational responsibility. Each individual should look at what they can do differently to improve their situation and do a temperature check within their wider teams
Finance monthly report The Month 12 draft accounts for 20/21 have been completed and have been submitted to auditors; a breakeven position is predicted. The finance team is currently working through the planning guidance for 21/22 (for the first half of the year). The CCG is predicting an £8m deficit, we have indicated to the ICS that we will manage our position in place from the total overall resource; this may mean drawing on some of the non-recurrent monies.
Digital monthly report An update on the rollout of the windows 10 upgrade was provided. Rollout had been planned for the end of April but further testing is needed on a number of non-clinical apps. Conversations are being held with practices around which apps are necessary to manage their day to day business. A decision has been made to extend the testing period to mid-May to ensure a safe transition.
Quality monthly report
23 24 The update around vulnerable children was noted to be generally positive. Ofsted are currently reviewing progress made by BMDC and NHS and the SEND review is likely to commence in June. Post Covid and recovery: As we move to more collaborative working in a system space, it was noted we need to consider how we make sure there is oversight of the totality of our system in terms of quality assurance.
CCG corporate risk register Members reviewed the risk register prior to presentation to the Governing Body. All Covid risks have moved over to the corporate risk register and all risks will be reviewed on a bi-monthly basis. It was agreed the risk register will need to be reviewed in light of the transition to an ICP.
Red hubs Due to the decreasing numbers of patients using the red hub at Hillside Bridge, SLT supported a decision to close the hub in June 2021. An exit strategy was being developed to support practices to manage ‘red’ patients and a plan will be developed to step up the service again to deal with any further waves of Covid-19.
5 May 2021 Act as One Updates were provided from the Act as One programmes, this included; 15 new pathways available to “go live” on Assist following LMC review and sign off; funding has been secured for the COPD Digital Hub pilot for patients at home with the Luscii app and an engagement project with Bengali community to develop culturally appropriate resources has commenced.
Our Integrated Care Partnership (ICP) The ICP Development Programme was signed off by the ICP Executive Board on 30 April 2021 and the ICP programme Board is due to be launched. This group will agree governance arrangements, clarify the leadership arrangements for work streams, scope, and plan work streams, including interdependencies and step up our system communications on ICP.
Finance update SLT received a presentation which set out the operational budget for the period April 2021 to September 2021 (H1), it described the financial risks associated with operating under the financial arrangements for H1 and the combination of mitigations in place to manage this risk.
System (ICS) and place (ICP) updates The System Leadership Executive Group discussed the draft structure and functions of the ICS Body.
Windows 10 VDI Migration Schedule and Testing Status It was reported that we are currently in phase 2 of the plan: GP roll-out is due to be completed by 21/05/21. It was noted the roll out to Craven practices was delayed slightly (11/06/21) as they needed to migrate to VDI first. It was noted there was concern around the slippages and from a GP practice point of view, clinical safety was still a concern.
12 May 2021 Inverting the Power to Act – Community Partnerships (CPs) The focus of the discussion was to look at how the CCG can use resources to enable connections into communities and strengthen the value of the CPs. It was noted how the CPs are the driving force of much work being done across place and how this will continue through partnership work to ensure the voice of communities is responded to.
Monthly report – performance Whist the Covid situation is improving there are pressures in other areas e.g. waiting lists and increasing attendance at A&E by patients reluctant to accept telephone/virtual appointments. It was noted that more in depth work needs to be done around the new state of primary care to engage with people and support practices to deliver the required messages.
DHSC white paper
24 25 Feedback from the ICS design and transition group: It was reported that consistency will be required across the five ICPs; the chief nurses have been asked to look at gaps in the ICP development framework around quality. It was noted the national HR guidance around appointments to ICS and employment commitment has now been postponed until July
WellbeingandAble staff network update Members of the group reported how they had been involved in the review of a number of HR policies including the recruitment and retention policy, the homeworking policy and the sickness policy. A discussion was had on how to support carers within the workforce with suggestions on the development of a carer’s network within the CCG.
Windows 10 VDI Migration Schedule and Testing Status Four sites have migrated to windows 10. Due to a number of issues, the plan to move more sites across to Windows 10 is deferred to next week. A number of issues around printing were reported.
19 May 2021 Strategic focus: Emerging Integrated Care Partnership (ICP) Strategy An initial draft of the strategy was presented. It described the added value an ICP would bring to our place; this included a shared purpose, value for partners and population. The strategy will create a shared responsibility, make best use of assets/resources, facilitate collaboration, remove barriers, support longer term planning, help make tough decisions together, remove duplication and waste. It will provide a shared purpose everybody can relate to, bridge the gaps, and provide equity for our population.
Monthly report: Digital update IT systems performance remains at red, it is anticipated the data centre upgrade and move to Windows 10 will resolve this. The move to a secure email service needs to be completed by the end of June; if this is not completed NHSD may escalate the non-compliance to NHSE/X who can take regulatory action. The COIN network re-procurement is going through the final re-procurement stages.
Windows 10 roll out / impact in practices: There are a number of unresolved issues around printing for some applications (This was noted to be prescriptions) and some web sites are not opening with the designated desktop browser. It was expected that a network configuration change would be required.
Children’s Services monthly report CLA: revised trajectory shows current back log (140 Initial Health Assessments, 85% Review Health Review H Assessments) will be cleared by September and June 2021 respectively. A Designated Doctor for CLA is in place and helping to develop a sustainable system model for Des Doctor + Named Drs from April 2021. A SEND inspection was expected in June. It was noted that it is important that as a system we collectively own the risks particularly as we move into an ICP.
Joint Placement panel update SLT received an update on Doncaster team Joint Placement Panel and the implications for Bradford should they adopt the model fully was shared. A move to the model was approved subject to some further clarification around funding elements and timescales.
26 May 2021 Strategic focus: Quality concerns - Attention Deficit Hyperactivity Disorder (ADHD) treatment It had been reported that the Individual Funding Request Panel had received a number of requests for patients to be referred to a private provider for assessment, diagnosis, and subsequent treatment for ADHD. It was reported that the CCG medicines optimisation team had some concerns around safety issues; prescribing and monitoring of medication. It was agreed that the CCG would write formally to the provider and set out our expectations around quality, advising that if they could not meet these criteria the CCG would instruct GPs not to refer to their service.
Monthly report: Quality update Updates were provided on the progress on LeDeR and the SRO role; Changes to neonatal BCG vaccination; Host commissioner arrangements, it was noted that there is pressure on the CCG team
25 26 due to the short term Interim arrangements being undertaken by the CCG and the targeted work ongoing to address vaccine uptake within specific communities.
System (ICS) and place (ICP) updates SLT received a presentation which described a draft structure and function of the ICS body. It was noted that the model does not have to be perfect by April 22, it just has to be ready to start the journey, and, as a place, Bradford district and Craven is in a good position because of how we work already. The first meeting of the ICP Development Board has taken place.
CCG corporate risk register Members reviewed the risk register prior to presentation to the Governing Body. All Covid risks have moved over to the corporate risk register and all risks will be reviewed on a bi-monthly basis.
Weekly update of Windows 10 roll out / impact in practices It has become apparent that THIS did not complete a full technical and site readiness checklist which has resulted in a practice having to abort migration. It was noted to go live without adequate controls and internal assurance in place could cause operational and clinical risk. The CCG Digital team will now undertake a joint review of the pre-migration (technical and site readiness) checklists prior to go/no-go decisions being made. Work was ongoing to resolve the prescription printing issue.
2 June 2021 Monthly report act as one Members received an update on progress in a number of areas including; Two new services for eyes and plastics; the “Kindness, Compassion and Understanding” campaign, designed to support young people with their mental health and wellbeing; A bid for an Innovation Hub, linked to the Ageing Well programme and entries for the HSJ Awards 2021.
System (ICS) and place (ICP) updates Members received feedback from the West Yorkshire System Leadership Executive Group (SLEG) and Joint Committee of CCGs. The ICS transfer of functions group were undertaking some work to map out what the current CCG/NHSE/ICS functions are and which functions are statutory/non statutory/outsourced etc. where the functions will sit in the new ICS/ICP. This group will oversee and coordinate the close down of functions, working to timelines for closedown, transfer, and shadow arrangements.
Equality, diversity, and inclusion update The first quarterly update was provided around the progress around the Workforce Race Equality Scheme (WRES) action plan for 2021/22 and also additional progress made against the actions identified in the workforce equality work plan which was drawn up from discussions at the (BA)ME and WellbeingAndAble staff networks. It was noted that the future of the networks as we move through transition to an ICP needed some consideration and needed to be linked into the ICP development programme and ICS arrangements.
Weekly update of Windows 10 roll out / impact in practices The issues affecting electronic prescription printing is still ongoing. THIS have being working closely with VMware and confirmed that the issue affecting electronic prescription printing was a problem with the software and VMware have accepted responsibility and are looking for a solution. This may impact on the roll out of windows 10. The timescale for the secure email migration which is linked to the DSP Toolkit submission may also slip as this cannot be completed until the Windows 10 migration is complete.
9 June 2021 ALT Focus: Shaping our future ALT led a discussion around how to shape our future. Our vision is Act as One; this works better in some areas than others e.g. respiratory, healthy minds and ageing well. We need to learn from these, understand the building blocks that made them successful and what are the practical things we can do to support all teams to work this way. Colleagues shared experiences around how they feel they have permission to act but noted this not happening across all the system and there is work to do to bring colleagues and partners with us and move this forward and be a high trust system.
26 27 Monthly report: Performance It was reported that A&E attendance has increased in line with pre Covid levels for both acute trusts; Airedale Hospital Foundation Trust in particular has been affected by an increase in levels not seen for over 12 months. Waiting times at both acute trusts are generally continuing to improve.
DHSC white paper - ICS/ICP transition The WY&H Future Design and Transition Group is looking at work streams and helping to design the core parts of the ICS operating model. A task and finish group is looking at the approach to accountability and assurance to support the work of the ICP development framework. Work is progressing around the ICS payroll functions.
Preparing for the COVID-19 public inquiry Members were informed that preparations were underway by the government for a UK wide COVID- 19 statutory public inquiry. All four devolved governments of the UK have agreed to hold collectively a statutory inquiry that will have entire government response within its scope which will include health. The inquiry is scheduled to commence in the spring of 2022 and each organisation is recommended to appoint an inquiry single point of contact and its own inquiry lead. Record keeping will be key to the inquiry.
Windows 10 VDI migration schedule and testing status Mores sites have gone live and learning has been taken from the initial transitions. Electronic prescription printing is still an issue and a conversation with the VMware relationship manager is planned to understand the position and agree a way forward as a matter of urgency.
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NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 6i
Name of meeting Governing Body Meeting date 13th July 2021 – Title of report CCG Finance Report for the period Report author(s) Diane Lawlor Strategic to the 31st May 2021 Head of Finance Lead(s) / SRO Robert Maden – CFO Report lead(s) Robert Maden - CFO
Paper summary and/or key discussion points
This report provides information on the financial position of the CCG as at the 31st May 2021. As for the last six months of the 2020/21 financial year, the CCG has received a fixed funding envelope for the first six months of the 2021/22 financial year which it is expected to manage costs within, except for specific items where additional cost reimbursement will be available. Therefore, this report concentrates on financial performance for the six months from April 2021 to September 2021 (H1). Details of the finance regime and operational requirements for the period October 2021 to March 2022 (H2) are yet to be confirmed and there will be a further planning process for this period.
Appendix 1 contains information on summary budget performance for H1.
Key Points:
The gross expenditure budget approved by the Governing Body has increased from £512.9m to £519.1m due to the confirmation of further national service development funding of £3.7m, the inclusion of the full Additional Roles Reimbursement Scheme budget for the CCG (£1.9m) and a correction to the reimbursement expected under the Hospital Discharge Scheme (£0.6m). These adjustments have not affected the planned break-even position, or the savings target that needs to be achieved.
Due to the very limited activity information available on areas of variable expenditure such as prescribing and continuing healthcare, performance on net commissioning budgets is shown in line with plan (year to date and for H1). Full reimbursement of costs from the Elective Recovery Fund and the Hospital Discharge scheme has been assumed in this position.
Year to date and forecast H1 running costs are in-line with budget and within the pro-rata share of the CCG’s published running cost allocation.
Savings schemes opportunities are being reviewed, but are not expected to have a significant impact in H1. Therefore, contingency reserves of £1.45m have been released to offset the savings shortfall relating to the planning requirement of savings equating to 0.28% of the resource baseline.
The balance of the savings target of £5.3m is shown as residual financial risk that needs to be managed in the Bradford Place in order for the CCG to meet its financial plan for H1.
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The summary of Bradford Place financial performance shows early indications that there will be a level of underspend to help offset the residual financial risk of £5.3m that is within the CCG’s financial position and this will updated as we progress through H1.
In addition to the savings shortfall risk, the other main financial risks relate to:
- full reimbursement of Elective Recovery Fund costs as these are based on an ICS performance level assessment; and - continuing care demand pressures. As information becomes available on actual activity, any pressures arising from these risks will be included in the reported financial position to the extent that they cannot be managed by the mitigations set-out in the risk Table in the report.
Overall, based on the forecast commissioning budget performance and subject to the management of the residual financial risk by health organisations in the Bradford Place, the CCG currently expects to meet its financial plan targets for H1.
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
Contributes to financial sustainability and improves quality of commissioned services.
Purpose assurance Information Decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
The Governing Body is asked to: 1. Note the year to date financial position as at Month 2 (May) and the forecast financial position to September;
2. Note the level of residual financial risk for H1-2021/22 and how this is expected to be addressed; and
3. Note the uncertainty relating to the finance regime and funding settlement for the second half of the financial year.
29 Page 2 of 3 30 Appendices (or other supporting papers)
1. Summary CCG Financial Performance
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BRADFORD DISTRICT AND CRAVEN CCG
FINANCE REPORT FOR THE PERIOD TO 31ST MAY 2021 (MONTH 2)
1. Introduction.
1.1 This report provides information on the financial position of the CCG as at the 31st May 2021 and the forecast financial performance for the period to September 2021.
1.2 The resource allocation and budgets cover the period April to September 2021 and reflect the amounts in the H1 2021/22 Financial Plan approved by the Governing Body in May 2021.
1.3 Financial performance for this period is based on the application of H1 Financial Planning and Contracting guidance which requires that block contract arrangements for NHS providers continues in 2021/22. Under these arrangements, block contract values for our main NHS Trusts have been rolled forward from H2 2020/21 and an uplift of 0.5% applied in line with national guidance. This excludes the uplift for the Agenda for Change pay award for the current year which has not been settled yet. Budgets have been set based on the uplifted block contract values and therefore performance is shown in-line with budget.
For other services, where activity information is available, this has been used to support the assessment of financial performance. The main budget areas concerned are Primary Care Prescribing and Continuing Healthcare, but as there is only very limited activity information available at this stage (no prescribing, month 1, continuing healthcare still to be validated) these have also been shown in-line with budget.
The additional costs related to responding to the pandemic are included in the relevant budget line and continue to be highlighted on the budget report as COVID-19 costs.
1.4 The CCG has received a funding envelope for H1 2021/22 which it is expected to manage within except for specific items where additional cost reimbursement will be available. These include funding for the Hospital Discharge Programme, the Elective Recovery Fund and the Additional Roles Reimbursement Scheme for Primary Medical Care. Expenditure budgets have been shown gross of these funds.
1.5 Key points for Month 2 performance are highlighted for the Committee.
2. Changes to Resource Allocation and Budgets.
2.1 There have been some revisions to the budget approved by the Governing Body which relate to additional national Service Development Funding allocations and adjustments to ‘out of funding envelope’ reimbursements. The movements are summarised as follows:
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£'000 Approved Expenditure Budget (Gross) 512,937 Additional Service Development Funding 3,704 Correction to Elective Recovery Fund reimbursement 15 Correction to Hospital Discharge Programme reimbursement 591 Inclusion of maximum Additional Roles scheme reimbursement 1,879
Expenditure Budget (Gross) at Month 2 519,126 Out of Funding Envelope Reimbursements -5,376 Expenditure Budget (Net) at Month 2 513,750
2.2 The opening allocation for the CCG for the period April to September 2021 is £507.4m. Service Development and Service Recovery Funding allocations of £6.3m are also included at month 2 and have been reflected in relevant budget lines. At Month 2, all timing differences between notified opening resource allocations and financial plan assumptions have been eliminated with the Month 2 resource allocation matching the CCG’s expenditure budget.
April - September
Opening RRLA Closing allocation (non recurrent) allocation April 502,307 5,156 507,463 May 6,287 6,287 June 0 July 0 August 0 September 0 Actioned to date 502,307 11,443 513,750
2.3 The income budget for items reimbursed outside of the fixed funding envelope comprises:
£'000 Hospital Discharge Programme -1,182 COVID-19 Vaccination Programme 0 Primary Care Additional Roles -1,879 44% of maximum allocation of £4,235k Local Independent Sector Activity -2,315 -5,376
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3. Financial Performance at Month 2 – Key Points.
3.1 Overall Position
April 2021 - September 2021 April - Year to Date FOT September May of which is of which is Over / Over / Budget Budget COVID19 COVID19 (Under) (Under) Costs Costs Commissioning Budget 517,852 172,602 254 716 432 2,060 Savings Target -6,714 -2,238 2,238 0 6,714 0 Contingency Reserves 2,540 847 -485 -1,454 Running Costs 5,448 1,816 -14 8 0 75 Residual Financial Risk 0 0 -1,712 0 -5,260 0 Gross Expenditure 519,126 173,027 281 724 432 2,135
Additional funding to reclaim -5,376 -1,776 -281 -397 -432 -1,182 Net Expenditure 513,750 171,251 0 327 0 953
Net Summary: Net Commissioning Budget 512,476 170,826 -27 319 0 878 Savings Target -6,714 -2,238 2,238 0 6,714 0 Contingency Reserves 2,540 847 -485 -1,454 Running Costs 5,448 1,816 -14 8 0 75 Residual Financial Risk 0 0 -1,712 0 -5,260 0 Net Expenditure 513,750 171,251 0 327 0 953
The year to date and forecast positions for commissioning costs within the fixed resource baseline show expenditure in line with budget. This position is net of costs for which additional funding can be claimed. For running costs, there is a small year to date underspend of £14k with H1 expenditure forecast to be in line with budget.
Underspends and overspends against budgets for which additional funding can be claimed, i.e. the Hospital Discharge Scheme and Elective Recovery Fund, are offset by a corresponding change in the value of the reclaim resulting in no impact on the CCG’s financial position.
The position includes a net £0.33m and £0.95m for year to date and forecast COVID-19 costs.
No savings have currently been identified for H1 and so contingency reserves are being used to offset expected plan savings of 0.28%, which equates to £1.45m.
The plan for the balance of the savings target of £5.3m is shown as residual financial risk and is expected to be covered by “Bradford Place” savings, although the source is yet to be confirmed.
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There is also a potential ICS level risk relating to achievement of Elective Recovery Fund baselines, but this has not yet been quantified and does not form part of the reported CCG financial position.
3.2 Covid19 Costs Covid19 costs against budget are detailed in the following Table. There is a forecast underspend against the budget for primary care Red Hubs as the site at Hillside Bridge closed at the end of May 2021. Similarly, costs of admin staff support to Covid19 services have reduced although the forecast reflects that there will be some continued support until September 2021.
April - September 2021 April - Year to Date FOT September May Over / Over / Budget Budget (Under) (Under) Patient Transport Services 336 112 18 0 Telehealth 297 99 2 6 Primary Care Red Hubs 176 59 0 -117 Primary Care Super Rota 180 60 -31 0 Admin Support Costs 150 50 -42 -75 1,139 380 -53 -186
3.2 The main factors affecting performance are: There is little or no activity information available to date on the CCG’s main budget areas that are subject to variation and so in most areas, performance is shown in-line with budget.
Although there is a degree of uncertainty around the mechanisms and levels of funding for “outside of the envelope” reimbursements (mainly the Elective Recovery Fund), it has been assumed that these will be received in full at the values shown.
Budgets and forecast positions include £6.3m of Service Development and Service Recovery funding which is expected to spend in full.
Savings plans are yet to be finalised and so the likelihood is that the savings will only begin to impact on the financial position in H2. Achievement of a breakeven position in H1 therefore requires the release of contingency reserves leaving a residual financial risk of £5.3m.
3.3 Appendix 1 shows a summarised budget position and a detailed break-down of each budget area.
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4. Performance Against the Savings Target.
Whilst it is unlikely that there will be savings generated in H1, work is continuing in the following areas to identify savings schemes that will impact in H2.
Prescribing: a) Low Priority Prescribing; b) Cost Effective Medicines Choices (Optimise Rx); c) Rebate scheme; and d) Other schemes relating to formulary adherence.
Continuing Healthcare assessment processes being reviewed for consistency with national framework to ensure that eligibility criteria are being correctly applied.
Some budget areas may start to generate a level of non-recurrent underspend and this will contribute to the H1 savings target, although this is not expected to be a significant value.
5. Bradford Place Financial Performance.
As at Month 2, financial performance for Health organisations in the Bradford Place shows:
Variance Variance fav. / fav. / Plan (adverse) Plan (adverse) Airedale NHS FT 0 1,110 0 0 Bradford Hospitals NHS FT 0 1,100 0 0 Bradford District Care NHS FT 0 0 0 0
Bradford District and Craven CCG 0 0 0 0
Total Position 0 2,210 0 0
Year to date performance shows a £2.2m favourable variance to Plan for the NHS Trusts, and whilst the forecast H1 position is in line with Plan, the indications are that there will be a level of underspend to help offset the residual financial risk of £5.3m that is within the CCG’s position. Place performance will be reviewed and reported monthly as we progress through H1.
6. Financial Risk.
Current financial risks are set-out in the following Table:
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Risk Mitigation Savings Target shortfall. - Budget performance review to identify in-year savings (recurrent and non-recurrent). - Use of contingency reserves. - Place based risk share arrangements. Activity Risk – continuing healthcare - Review application of eligibility criteria and contributions to jointly funded care packages. - Ensure appropriate costs fully claimed under the Hospital Discharge programme. - Use of contingency reserves. Elective Recovery Fund Recovery less - Trusts plans are to exceed ERF than 100% of activity cost. baselines. - Significant activity expected to be carried out under the Yorkshire Clinic contract for the Bradford Place. - Application of WY&H ICS risk share arrangements that recognise delivery by Place. Agenda for Change pay award settlement - Budget setting based on a 2% pay could create a cost pressure on CCG staff award and so the risk should be budgets. low.
There is also a potential risk relating to reimbursement under the Hospital Discharge scheme as the budget available for reimbursement has been capped at an ICS level. The current assessment of commitments against this budget for all five CCGs in the West Yorkshire and Harrogate ICS is that they are well within the capped value, both overall and individually. This position will be kept under review as reimbursement claims values are confirmed.
As for H2 last year, the overall financial risk management approach continues to be to: Manage costs within the CCG’s resource baseline where possible; Apply the Bradford Place financial risk share arrangements to manage the Place financial position; and if necessary Apply the WY ICS financial risk share arrangements to get organisations as close to break-even as possible.
Therefore, on the basis of the forecast operational budget performance and the risk mitigations identified above, the CCG expects to meet it break-even financial target for H1 - 2021/22.
At this stage it is not possible to set-out the likely financial position for H2 – 2021/22 as the funding settlement for the last half of the financial year remains to be confirmed.
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7. Recommendations.
The Finance & Performance Committee are asked to:
a) Note the year to date financial position as at Month 2 (May) and the forecast financial position to September;
b) Note the level of residual financial risk for H1 – 2021/22 and how this is expected to be addressed; and
c) Note the uncertainty relating to the finance regime and funding settlement for the second half of the financial year.
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APPENDIX 1
Summary Financial Performance for the period to 31 May 2021
April 2021 - September 2021 April - Year to Date FOT September May of which is of which is COVID19 COVID19 Budget Budget Over / (Under) Over / (Under) Costs Costs £'000 £'000 £'000 £'000
Acute Care 240,588 80,180 278 0 432 0 Urgent Care 19,171 6,391 24 0 73 0 Community Services 38,605 12,868 -24 231 -73 639 Personalised Commissioning 29,390 9,797 3 397 0 1,182 Mental Health and LD Services 54,310 18,103 0 0 0 0 Prescribing 55,385 18,462 0 0 0 0 Primary Medical Care 56,100 18,700 0 0 0 0 Other Primary Care 4,924 1,641 0 88 0 239 Other Commissioning 15,836 5,284 -27 0 0 0 RIC Investments 3,543 1,176 0 0 QIPP Savings Balance -6,714 -2,238 2,238 6,714 Residual Financial Risk 0 0 -1,712 -5,260
Total Operating Costs 511,138 170,364 780 716 1,886 2,060
Contingency Reserves 2,540 847 -485 -1,454 Other Reserves 0 0 0 0
Total Reserves 2,540 847 -485 0 -1,454 0
Total Healthcare Expenditure 513,678 171,211 295 716 432 2,060
CCG Running Costs 5,448 1,816 -14 8 0 75
Gross Expenditure 519,126 173,027 281 724 432 2,135
Additional funding to reclaim -5,376 -1,776 -281 -397 -432 -1,182
Total Net Financial Position 513,750 171,251 0 327 0 953
MEMORANDUM Additional funding to reclaim: Hospital Discharge Programme -1,182 -394 -3 -397 0 -1,182 COVID-19 Vaccination Programme 0 0 0 0 0 0 Primary Care Additional Roles -1,879 -626 0 0 Elective Recovery Fund -2,315 -756 -278 -432 -5,376 -1,776 -281 -397 -432 -1,182
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39 40
NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 6ii
Name of meeting Governing Body Meeting date 13th July 2021 Gill Paxton Associate Director of Quality and Nursing Title of report Patient Safety and Quality Report author(s) Improvement report Michelle Turner Strategic Director of Quality and Nursing SRO Michelle Turner Michelle Turner Lead(s) / SRO Dr James Thomas, Clinical Chair Report lead(s) Dr David Tatham ,Clinical Lead
Paper summary and/or key discussion points
This report provides an overview and key messages of the following:
Living with Covid-19 and system resilience Overview of system health provider quality outcomes - provider specific Overview of Medicines Optimisation - key areas of focus– including Covid-19 vaccinations, Overview of Research and Development (hosted service WYICS) Safeguarding Adults and Children Overview of Care of Vulnerable Children including progress against key outcomes of concern. Host Commissioner responsibilities for people with Learning Disabilities and Autism in inpatient settings Learning Disability Mortality Review Programme System Quality Committee areas of focus – including West Yorkshire Quality group proposals and key areas of focus to improve quality at scale in ‘place’ (Bradford District and Craven).
Each month the CCG’s senior leadership team has also received a more detailed overview of the emerging issues and the steps taken to mitigate. These have been reviewed by the CCG’s Quality Committee along with the CCG’s corporate risk register which includes risks arising from Covid-19).
Key issues regarding living with Covid-19, the roll out of the vaccine, system resilience, the care of vulnerable children and progress by the system quality committee are noted
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
The quality and safety of services is core to the CCG’s strategy. Patient feedback is included within the paper and a more detailed overview will be considered at the CCG’s Quality Committee. Equality Impact Assessments have been conducted throughout the period and the outcomes have informed the CCG’s approach to risk assessment and to mitigation.
40 Page 1 of 2 41 Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
The Governing Body is asked to: Note the information and assurance provided by the report, including key actions taken by the CCG to manage quality and safety issues and risks arising from COVID-19 and non-covid-19 issues. Note the substantial progress made by ‘health’ in address some of the concerns raised about the care of vulnerable children Note the increasing emphasis on ‘place’/’system and collaboration to address challenges and poor outcomes together rather than on an individual basis with each provider.
Appendices (or other supporting papers)
1. Governing Body Quality Report (July 2021)
41 Page 2 of 2 42
Governing Body Medicines Covid-19 Quality and Safety Related IssuesSafeguarding and JulyRisks 2021 Optimisation
Michelle Turner Patient Quality safety Improvement
Research & Personalised development Commissioning
42 43 Quality and Safety COVID-19 Headlines 13th July 2021
Living with Covid-19 Across Bradford District and Craven; • Infection rates across Bradford have increased to 123 per 100 000. The higher infection rates are with younger residents. • Bradford had the 22nd highest Covid 19 rates in the country , now 26th highest • Uptake of vaccine continues to be lower in central areas and areas of deprivation • Increased number of drop in vaccination clinics being run to increase uptake and the regular use of the vaccine bus. • Care home infection rates remain stable, 1 home in Bradford have a reported outbreak within the 0-28 day cycle and Craven has 0 homes. COVID-19 support team has switched to recovery focus. • There is a high demand on all services across the whole system, this may impact on Care homes and home support , general practice and other parts of health and care system. System workforce issues constraint on delivery. System Quality Summit to be planned for late July 2021 • Mandatory COVID-19 vaccinations for all care homes staff – may impact on workforce and sector sustainability • CQC publication on COVID-19 Deaths by Care Homes (10/4/20 – 31/3/21) – Will bring potential media attention on individual care homes and also scrutiny of system response. • Red hub at Hillside Bridge closed on 28 May 2021. A 2 week step up plan is in place if required. Moderna is the third vaccine to start being used in the district.
43 44 Quality and Safety Performance Overview 13th July 2021 Overview of system provider quality outcomes (BTHFT/ANHSFT/BDCT/Primary Care/Care Homes) 18 week performance continues to improve as elective capacity comes back on stream. As a result, BTHFT has seen a decrease in those waiting over 40 weeks with 1,676 waiting >52 weeks and a further reduction to 14 in April 2021 of those waiting >104 weeks. ANHSFT saw an improvement in the number of patients waiting >52 weeks for treatment from 1,041 to 856 in April 2021. Delays from Covid-19 still are having an impact upon BDCFT’s community dental service, although the number of patients on the waiting list has decreased as acute theatre capacity has increased, Diagnostic performance continues to improve, with both Trusts making use of Independent Sector capacity. ANHSFT not able to achieve either the 2 week wait or the 62 day cancer standards in April 2021, and BTHFT’s 62 day performance was also below the national standard, although the reduction in those who have already waited over 62 days continues. Increased referral rates continue to put pressure on some community mental health services, including Improving access to Psychological Therapies (IAPT) and Child and Adolescent Mental Health Services (CAMHS) . Capacity drawn from broader Multi-Disciplinary teams (MDTs) to support allocation of duty, which means waiting times have been met for 1st & 2nd appointments. NHSE/I reviewing out of area placements for all CCGs 27 for BD& Craven which includes Psychiatric Intensive Care Units (PICUs)
BTHFT saw A&E attendances increase in line with44 pre Covid-19 levels, and ANHSFT saw attendances increase to levels not seen for over 12 months. 45 Quality and Safety Provider Overview 13th July 2021
Overview of system provider quality outcomes (BTHFT/ANHSFT/BDCT/Primary Care/Care Homes) • The CCGs CHC assessment backlog as a result of Covid-19 has now been cleared.
Serious Incidents: Providers continue to ask for managed extensions to allow more complex investigations to take place. A resumption of virtual coroners inquests has exacerbated the delays as members of the Provider clinical governance teams are required to attend. • BTHFT- There was a Safeguarding SI recorded on STEIS system pertaining to a child neglect case who presented at A&E, safeguarding and police aware. This case was not attributed to BTHFT care provision. Another SI reported involved a treatment delay within Ophthalmic surgery. • Yorkshire clinic – A new Matron has joined the Patient safety team. Quality account received • BDCFT- there has been a community suicide SI alert of a reported hanging. The Quality account has been received and a response sent from BDCCCG. • ANHSFT – No SI’s reported. The quality account has been received and a response sent by BDCCCG • Recent concerns being investigated regarding Mediscan’s performance with ultrasound scans. CQC and NHSE/I informed and country wide investigations are ongoing led by Manchester host commissioners. • There is a watching brief on a reported incident with patient outcome letters (including discharge summaries) from Leeds Teaching Hospital Trust. Letters are not being electronically received by GP practices in Bradford where necessary. 45 46 Quality and Safety Care Home overview 13th July 2021
Overview of system provider quality outcomes (BTHFT/ANHSFT/BDCT/Primary Care/Care Homes) • 7 care homes currently rated as inadequate and placed in special measures • Concerns raised re: Southfield Care Home access to Indemnity Insurance due to an inadequate rating. Further exploration is underway involving BMDC, the Director of Adult Social Care and the Department of Health and Social Care. BMDC, General Practice & Partners continue to support care homes to improve as per enhanced surveillance processes. • Although infections rate are currently low, the increase in community infections has resulted in a small number of care homes reporting an outbreaks. These are being supported by the Covid-19 support team, infection prevention and control team and the super rota. Care@Home/Ageing Well Key messages • Review across Primary care networks is in progress to establish the current state of implementation of Enhanced Health in Care Home specifications against the GP Directed Enhanced Service (DES). Further work is ongoing to engage with the community nursing service and Allied Health Professionals working within Care Homes Good News: • Bradford District and Craven has been identified as exemplars for the implementation of Restore2 training by Yorkshire & Humber Patient Safety Collaborative – A methodology and training resources shared across the network to promote a consistent approach across the Integrated Care 46 System to support care Providers to recognise and respond to clinical patient deterioration. 47 Quality and Safety Primary Care overview 13th July 2021
Overview of system provider quality outcomes (BTHFT/ANHSFT/BDCT/Primary Care/care homes) Quality Assurance – general practice • The CQC has published their National report on DNR’S/CPRs ( Do not resuscitate/cardiopulmonary resuscitation) and best practice for primary care. This has been shared with Primary Care Networks Clinical Leads for implementation into General Practice. • New process for CCG practice quality and assurance reviews was agreed by PCCC on 11th May. The new process has been communicated to practices and is now re-commencing. • Wibsey practice CQC inspection was “requires improvement”- re-inspected on 5th May – now “Good” in all 5 areas. • Following a recent visit to Farrow Medical Practice by the PCT team the contracts assurance group (CAG) supported the recommendation to remove the practice from enhanced surveillance. • Meetings now arranged to review rate of Anti-psychotic prescribing in dementia patients in Bradford • Meetings being arranged to recommence Post Infection Reviews (PIR) in primary care
47 48 Quality and Safety Overview of Medicines Optimisation 13th July 2021
Overview of Medicines Optimisation Key topics: • Independent Provider of Psychiatric care - prescribing issues – the Comms team have been working with Practices. A request for information sent to the provider regarding their Quality Assurance process. • Link pharmacists scheme – positive response from consultation. To restart in July. • Warfarin monitoring – There is going to be a complete review of anticoagulation services in Bradford – • ICS Integrating NHS Pharmacy and Medicines Optimisation (IPMO) – ongoing Organisation development and Area Prescribing Committee alignment • QIPP planning for 21-22 is underway to ensure the alignment of system priorities • A framework for collaborative working between West Yorkshire & Harrogate Health and Care Partnership and the pharmaceutical industry is in underway.
48 49 Quality and Safety Overview of PCD 13th July 2021 Overview of Personalised Commissioning Continuing Healthcare • Bradford is an outlier with regards to CHC ( continuing health care) performance currently – work is underway to address the issues and streamline processes • The new referral caseload has a waiting list of 55. There is a large number of referrals being received. • The CHC joint oversight group (co-chaired with the LA) provides effective governance and quality surveillance, and receives input from the joint operational group • Trajectory to complete new cases set and meeting with NHSE this week to discuss low projection. • Comparisons being made to nearest neighbour Salford CCG, and across our “NHSE Cluster” • The residential and nursing contract co-produced with the Local Authority is near sign off stage. Audit • The Personal Health Budget audit is near completion Other • Deregistration of 1 Learning Disability nursing home and 4 residential homes underway - alongside individual CHC needs, wider work being considered around community nurse resource required. Children’s Continuing Care update • The Children’s audit has been signed off and action plan in progress. This includes a full review of the Children’s Continuing Care process.
49 50 Quality and Safety Overview of Research and Development 13th July 2021
Overview of Research and Development (hosted service WYICS)
• Covboost trial through BTHFT, https://www.covboost.org.uk/participate-bradford, liaising with practices to enable recruitment • LAMP (lowering antimicrobial prescribing) Report 16 sent to practices , LAMP will form part of the ongoing primary care antibiotic stewardship programme within the ICS AMR (antimicrobial resistance strategy) • Nick Hayward has stood down as GP clinical lead for Research, looking to recruit a new GP lead. • Our Future Health – Genomic research where Bradford has been selected of one of five pilot sites for this national endeavour • Genes and Health continues to recruit • MHRA (Medicines and Healthcare Products Regulatory Agency) Electronic Health Records guidance group to publish new national guidance next month • Attending NHSE workshops to understand the role of R&D in the ICS, Conversations with ICP leaders in each place have commenced • The Interrupted Time Series for CROP ( Campaign to Reduce Opiod prescribing to be published in Public Library of Science Medicine Journal. • Qualitative review of CROP to be published in British Journal of General Practice 50 • Shortlisted for a Pharma-times award for the vaccine trial work 51 Quality and Safety Overview of Safeguarding Adults 13th July 2021
Overview of Safeguarding Adults Covid-19 Quality and Safety Related Issues and • ARisks regionally developed safeguarding proposal has been drafted to inform and influence discussions regarding safeguarding at Place and on an ICS level. • The MCA ( Mental Capacity Act) assurance standards have been regionally developed and agreed, for implemented next year. • The regional MCA group will continue beyond April 2022 with health representation at place. • The team is providing support and a consultative role to the CCG applications, on behalf of Primary Care, to the Court of Protection where there is objections from family members to individuals receiving a Covid vaccination. • Safeguarding week (21st-28th June) offering a range of events to join, including a session delivered by Dr Khan, Named GP and Katrina Uttley, Deputy Designated Nurse: Safeguarding Adults.
51 52 Quality and Safety Overview of Safeguarding Children 13th July 2021
Overview of Safeguarding Children Covid-19 Quality and Safety Related Issues and • ARisks system wide workshop has taken place to gain consensus with health colleagues on progress against the CQC Children Looked after review action plan. • Additional resource for Child exploitation hub has been identified by the CCG. The model is under consideration. • Designated Dr and named doctor options paper re submitted to System Finance Committee following request for further clarification. Model agreed by SQC in quarter 4 2020/1 • Child Sexual Exploitation Assurance event has taken place with Multi Agency partners. Health specific assurance event to be held mid July with partners in attendance. • Children Safeguarding Practice Review (CSPR) was recommended following a Rapid Review Panel meeting for a child with significant disabilities and neglect. • Confidential multiagency enquiry ongoing. Concerns re legal framework under which health information sharing is being requested.
52 53 Quality and Safety Overview of Vulnerable Children 13th July 2021 Overview of Vulnerable Children SEND: The anticipated date of the Bradford SEND inspection is July 2021. Requests for information have commenced. Risks shared with the CCGs Quality Committee and the System Quality Committee.
CAMHS: • Thrive Outcome data report produced based on the agreed system metrics and shared with the Children’s Mental health and Young Peoples Leadership Team. BDCFT will lead on a Rapid Improvement Process around quality and data improvements (July-August 2021). Data shows improvements to waiting times from 15 weeks to 4 weeks and waiting times for treatment by CAMHS services (from 320 children to 210); caseloads are increasing (2,800 to 3,300) due to acuity of need. • High demand from Children Social Services for support to referrals which has led to redeployment of support to manage waiting times and caseloads. Joint Placement Panel and reset resource for additional capacity for individual complex cases. Risks will be shared with the Safeguarding Board to support development of system solutions (August 2021) . • BDCFT has carried out reviews on highlighted cases to identify learning and improvements. One Trusted Pathway - Additional investment needed to accelerate the implementation of the pathway. Date of first workshop to be confirmed when mapping and work on investment review is completed.
53 54 Quality and Safety Overview of Vulnerable Children 13th July 2021 Overview of Vulnerable Children Autism (Children and Adults):
Waiting lists continue to be very challenging. Children:1471 on waiting list at end of April 2021. Business case to address backlog and increased assessment capacity to address increasing referrals in development to inform September 2021 financial planning session. All Age: Draft Strategy produced. System discussions around a new approach to neurodiversity with a greater focus on intergenerational support based on need not diagnosis commenced 29th June 2021.
Children Looked After:
New clinical model for Initial Health Assessments (IHA) and review health assessments (RHA) in place. Marked improvements in IHA waiting times is now being seen. It is anticipated that these will be within normal limits by December 2021. Increasing concerns re lack of consent raised with BMDC and the Children Services Improvement Board. This presents a delay in the IHAs being conducted in a timely. manner. Plan to address concerns around timely access to Adoption Medicals in development. Issues noted re adult carer medical forms.
54 55 Quality and Safety Overview of LeDeR and Host Commissioner 13th July 2021 LeDER ( Learning disability mortality review programme - hosted Service for WY ICS LeDeR • National guidance outlines each ICS needs to nominate an Senior Responsible Officer for LeDeR by June 2021. Michelle Turner will pick this up on an interim basis. The new LeDeR Platform training is delayed by 3 weeks due to issues with the new database. Local Area Coordinators (LAC) are being updated. • No change in the cases completed from last month due to the temporary pause for database transfer led by NHSE. Host Commissioner responsibilities for people with Learning Disabilities and Autism in inpatient settings by April 2021 HOST Commissioner Responsibilities: • Discussions re the long term objective for a service design enabling WY ICS oversight are ongoing • Short term Interim arrangements are being undertaken by the CCG. There are risks to ongoing capacity and available resource to provide effective quality oversight. Awaiting confirmation of Transforming Care Partnership (TCP) funding for a band 7 role to support this. • The Memorandum of Agreement (MOA) and Quality schedule have been shared with Providers for consideration in line the collaborative ethos of our partner organisations. • Cygnet Woodside closed on the 28th May 2021 – and will remain dormant
55 56 System Quality Committee - Update July 2021 (Health and Care)
SQC 2020 -2021 key areas of focus WY System Quality Group Development • Draft proposals for the new ICS quality group have been shared with the WYICS design team, SQC, provider collaboratives and each ‘place’. The new arrangements to commence Sept/October 2021. Quality Dashboard being developed Nationally. Period of engagement with people, place and partners has commenced. • Alignment with NHSE/I oversight assurance framework and placed based standardisation.
ICP – System Quality Committee • System quality and performance workstream led by Michelle Turner –Initial feedback highlighting the requirement for clarity regarding; scope, the role of performance and the need to triangulate data and the relationships with stakeholders and supporting work streams. • Key workstreams mapped with named system leads. Further work required with ICP leads regarding areas of overlap with other workstreams. Key focus on opportunities to improve quality at scale, shared risks and shared challenges. • SQC meeting of 10th June 2021 received updates on; • Provider response to the Ockenden Report • Children & Young People Well-being Programme • Healthcare Partnerships/ICP and WY ICS development • System Finance & Performance Committee56 – Finance and Activity Planning and Prioritisation 57
Key performance and activity issues in the Bradford and Craven health system and our road to recovery
57 58 Purpose of presentation
• To present our Governing Body with an overview of system activity and performance as at late Spring 2021 • To summarise key priorities related to recovery and business as usual • To invite comment and challenge to ensure that we and the wider system are maximising our work and effectiveness to improve the health of local people
58 59 Contents
• Urgent care • Elective care including elective recovery programme • Independent Sector • Community • Mental health and learning disabilities • Overview of system – patient pathways
59 60
Urgent and emergency care
60 Access61 - West Yorkshire & Harrogate WY&H) perspective
• Primary care operating at a higher demand. • NHS 111 seeing high volumes of calls - the biggest impacts are weekday with a struggle to manage to morning peaks, school closure peaks and OOH peaks. • Anecdotal evidence from patients unable to access primary care so accessing Emergency Departments (ED) Receptionists advising ED Unhappy with long waits on the phone No face to face appointments available Distrust of remote vs. face to face appointments Paediatrics – parents unhappy with not being seen face to face so attending ED Patients delaying presenting and when they do access they are higher acuity/complexity
61 62 Demand (WY&H)
• Increasing demand on all ‘front door’ services – primary care, ED, social care, 111. • Increased demand on ED, Same Day Emergency Care (SDEC) and crucially community nursing teams to support GPs with patient bloods, observations etc. This is impacting on capacity particularly in Community where there has been no investment and which in turn impacts on admission avoidance and early supported discharge. • Demand significantly higher across Trusts than before Covid-19. Some Trusts have had their highest attendance figures ever. • Increasing trend in attendances at ED, particularly with young adults wanting same day resolutions. • Dealing with on day demand in community and primary care; including a challenge in the pace needed to implement Urgent Community Response Service. • ED evening surge with high volumes booking in between 5pm and 10pm. • Marked increase in arrival by ambulance so more focus on non-conveyance would be of benefit, funding for virtual frailty models would make a huge difference to patients, ambulance services and EDs. • Challenging to safely enact social distancing in EDs when demand and attendances are high. 62
Our63 Acute Hospital Services – Bradford and Craven • Both hospitals have recently seen A&E attendances increase to above pre- Covid 19 levels. • Urgent care teams at ANHSFT continue to plan for an anticipated further growth in demand for services. • Occupancy rates increased during April 2021 at ANHSFT, running at between 83-90% and length of stay (LOS) also increased, although the Trust maintained strong performance in > 21 days LOS throughout a challenging month (during April 2021 they had between 30-40 patients in the bed base who did not meet the criteria to reside). • At BTHFT – struggling with an increase in Covid-19 demand. The daily average number of patients with a length of stay >21 days remains better than target with an average of 69 patients per day in April 2021. Whilst this has increased due to a high number of patients who are medically optimised but not functionally fit to be discharged, the position for May 2021 is projected to improve to an average of 60 >21 days LOS.
63 Our64 Acute Hospital mitigating actions
ANHSFT planning includes: • Continuation of the minor injuries unit (MIU) model successfully trialled during the first Covid-19 peak in the area adjacent to the ED department; • Continued review of skill mix/medical workforce model, and shift times to meet changes in demand later in the day and evening period; • Screens purchased for waiting area to segregate hot (suspected COVID-19) /cold (non-COVID) patients and adults/paediatric attendances • Review of non-elective admission pathway and ED attendances, to identify alternative pathways of care based on an analysis of presenting need
Current work as part of the BTHFT urgent care work stream includes: • Proactive discharge planning for patients staying greater than 14 days; • Improving the footprint and flow in ED by merging ‘See and Treat’, Minors and Musculoskeletal clinics; • Working with 111, Primary Care and the wider system to develop pathways to the most appropriate service; • Embedding the medical and surgical ‘same day emergency care’ and; • Developing the Virtual Services Hub including64 acute frailty model
65
Elective care
65 66 Latest WY Acute Trusts Referral to Treatment position Overview of the data – West Yorkshire RTT position – 20/06/21
Total RTT Waiting List = 176,435 (197,344 including Harrogate)
52 Week Wait = 9,847 (10,862 including Harrogate) • Decrease of -235 (-265 with Harrogate)
104 Week Wait = 210 (219 with Harrogate) • 2 at AHFT (Airedale) • 28 at BTHFT (Bradford) • 54 at CHFT (Calderdale) • 125 at LTHT (Leeds) • 1 at MYHT (Mid Yorks) • 9 at HDFT (Huddersfield)
66
67 A WY ICS view ANHSFT (P2 activity is now in line with business as usual and P3 activity is starting to be recovered) • No cancellations of P1 activity or planned wider cancellations. • No known pressure on Critical Care capacity. • All theatres open and operational. Plans to carry out Saturday operating from end of June. • 80% and 90% of new and follow up Outpatient activity being delivered. • Diagnostics close to pre-covid 19 levels. • 104 plus week waiters – Plan in place for next stage of care. BTHFT (recovery still focussed on recovering the P2 activity and backlogs with some but limited P3 and P4 activity being undertaken at NHS sites) • No cancellations of P1 activity or planned wider cancellations. • Prioritising P2 patients and reducing the waiting times for these patients. • Use of insourcing with aim to clear backlog of P2 by end Q2. • Mutual support being provided by Independent Sector in Breast, Plastics, Urology and Pain. • Mutual aid from Airedale for ENT and potentially Ophthalmology. • Currently within baseline Critical Care bed base but currently seeing increase in Covid numbers. • 100% of Outpatient activity being delivered. • Diagnostics - backlog in Endoscopy and Echo – support from IS providers. • Staffing currently below establishment in theatres – looking to supplement by Insourcing • 104 plus weeks – all clinically reviewed. 8/28 plans in place in July. Priority 1-4 (P1 - intervention within 3 days, P2 - intervention within 4 weeks, P3 – intervention within 3 months , P4 – intervention >3 months) 67 ERF68 Position
Following the additional £1bn for elective recovery announced at the 2020 Spending Review, the Elective Recovery Fund (ERF) will be made available to systems that achieve activity levels above set thresholds (the levels funded from system envelopes). The threshold is set against a baseline value of all elective activity delivered in 2019/20 – for April 2021 it will be 70%, rising by 5% each month to 85% from July.
TOTAL YTD as at M2 April flex May Estimate [memo only - performance not cumulative]
Variance to Variance to Variance to Target Level Target Level Target Level ( ) = below Achievement ( ) = below Achievement ( ) = below Achievement target of 19/20 target of 19/20 target of 19/20 £000 baseline £000 baseline £000 baseline Airedale NHS Foundation Trust 635 89% 499 90% 1,135 89% Bradford Teaching Hospitals NHS Foundation Trust 217 73% 871 87% 1,088 79% Calderdale and Huddersfield NHS Foundation Trust 1,036 84% 1,513 96% 2,549 90% Leeds Teaching Hospitals NHS Trust 4,859 88% 4,199 92% 9,059 90% Mid Yorkshire Hospitals NHS Trust 2,542 92% 2,406 97% 4,948 94% South West Yorkshire Partnership NHS Foundation Trust 0 70% 0 75% (1,096) 0% Bradford District Care NHS Foundation Trust (0) 0% (0) 0% (1) 0% Leeds Community Healthcare NHS Trust 1 70% 0 75% (405) 0% PROVIDER TRUSTS TOTAL 9,290 86% 9,489 92% 17,278 88% NHS Bradford District and Craven CCG 1 70% 1 75% 1,033 93% NHS Calderdale CCG (0) 70% 0 75% (1,017) 0% NHS Leeds CCG 0 70% (0) 75% 768 87% NHS Kirklees CCG (0) 70% 0 75% (2,134) 0% NHS Wakefield CCG (0) 70% (0) 75% (2,001) 0% TOTAL Independent Sector Providers 1 70% 0 75% (3,352) 53% ICS TOTAL 9,290 84% 9,489 90% 13,926 83% 68 Our69 Acute Hospital Services – Elective
• With the increase in theatre capacity at ANHSFT returning back to a core theatre timetable and specifically with the restart of elective orthopaedics, activity during April 2021 increased and the Trust saw an improvement in the number of patients waiting >52 weeks for treatment from 1,041 to 856 in April 2021. • At BTHFT, performance also improved and the number of patients waiting over 18 weeks reduced due to a focus on long wait treatments and transfer of patients to Yorkshire Clinic. In April 2021 in those waiting over 40 weeks with 1,676 waiting >52 weeks and a further reduction to 14 in April 2021 of those waiting >104 weeks. However, the total waiting list at both Trusts increased due to growing referral demand from primary care. • Diagnostic performance continues to improve, with both Trusts making use of Independent Sector capacity and additional weekend sessions where possible. • AHFT was not able to achieve either the 2 week wait or the 62 day cancer standards in April 2021, and BTHFT’s 62 day performance was also below the national standard. Surgical prioritisation in line with guidance from the Royal College of Surgeons remains in place as do regular breach reviews, and the reduction in those who have already waited over 62 days continues. 69
70 Community Services
• BDCFT’s community dental service continues to be challenged by the impact of Covid-19 on delivery of the 18 week standard and although the number of patients on the waiting list has decreased as acute theatre capacity has increased, there are still 64 patients now >52 weeks. Theatre allocation at Airedale has been re-instated and community dental operating on site has recommenced in the Dales Suite. All referrals received at BDCFT are triaged and waiting lists are validated and monitored on a weekly basis. The Trust is exploring the potential for weekend waiting list initiatives. • The BDCFT’s Podiatry Service is now restored and operating at 99.7% RTT with 95% in the Rapid Access Service (2 day response time). • BDCFT’s Speech and Language Therapy Services are achieving 99% RTT (clock running). The waiting list for children requiring ongoing packages is significant at 1,730. • The CHC assessment backlog as a result of Covid-19 has now been cleared • Primary care appointment numbers have already recovered to pre-Covid 19 levels and are forecast to grow beyond Apr-Sep 2019 levels. As part of the National Access Improvement Programme funding, West Yorkshire is developing a data set tool kit which will be used to support a focused deep dive into the current access offer within one of the Primary Care Networks @ place. The key themes and regional support programmes will be shared and used to enable PCN’s to apply for support in improving access.
70 COVID-1971 vs Current Day Latest CCG position
71 72 Elective recovery
• Elective recovery continues to be challenged by Covid-19 • Patient choice – lifting of restrictions on social distancing + travel ( including challenges re community transport), isolation requirements, vaccination, safety concerns led to procedure delays • Theatre capacity and Staffing capacity – increasing staff absence due to rising community Covid-19 rates and some workforce still supporting other areas • Increasing non elective activity impacting on elective capacity and increasing elective referrals • Impact of social isolation and infection prevention and control measures • We have been able to support the backlog with additional capacity in the Independent Sector that came on line in May and June 2021, further providers and capacity are being secured where feasible but the limiting factor is funding to continue to support the arrangements.
72 73 Independent sector capacity
• The Bradford and Craven system secured 7,000 procedures with Yorkshire Clinic from April-September 2021, these were split proportionally based on the priority status and longest waiters being seen first. • The system secured 3,600 endoscopies and 1200+ echocardiograms with Westcliffe • The WYICS providers are keen to maximise the opportunity of partnership working with local NHS trusts and have established additional services like plastic surgery (Westcliffe) and vitreo-retinal surgery (Yorkshire Clinic). More are being explored with these and community based providers. • Patients are not attending or cancelling at very short notice. The slots could have been filled more easily pre Covid-19 but 3-14 day self-isolation requirements (dependent on the procedure) no longer means this is possible. • Some patients do not want to transfer their care to the WY ICS. • As patients have been waiting a number of months, their condition has deteriorated which means the surgery itself and patient’s own recovery is taking longer. 73 People’s74 experiences of elective care
• Feedback compiled in our Grassroots database is analysed by sentiment expressed to identity the proportion of positive emotions, such as ‘delight’ and ‘gratitude’ against negative emotions including ‘fear’ and ‘frustration’. • The first graph shows positive emotions associated with elective care have returned to slightly above their pre-Covid-19 levels. • Focusing on patient experience relating to the ‘Coordination’ theme, which includes waiting times, the second graph shows the percentage of comments linked to ‘Coordination’ which were positive. This has dropped significantly to just 8% in the current quarter. • Feedback compiled into Grassroots comes from Healthwatch, VCS engagement partners, CCG patient support team, Care 74 Opinion and NHS.uk People’s75 experiences of elective care
The ICS Planned Care Alliance has set out its plan for how we’ll work together across the whole of planned care to restore services. They have established a temporary virtual citizens’ panel to support in shaped the approach and communicating to the wider public and those affected by delays in care.
The panel is comprised of people who have been directly affected by delays in planned care services; it currently has nine members including two people from Bradford District and Craven.
Local Healthwatch across the ICS are also collecting insight from people who are waiting for treatment. A number of early themes have emerged: • Importance of timely communication with people whilst waiting for treatment • The significant impact it is having on people’s physical and mental health • Review of medication plans for long waits • Wider impact on their daily lives and coping strategies
These themes are echoed in the feedback collated into the CCG’s Grassroots
database. 75 76 What else is being done • Continued focus on the P2 and P3 patients. Specific focus on elective care recovery through the Access Programme (and other programmes) e.g., better use of technology and enabling self care • ANHSFT and BTHFT are looking to support each other where they have the same clinical teams particularly to address workforce issues. BTHFT are looking to secure additional capacity for some diagnostics • Continual review of patients on waiting lists to ensure no clinical risks (different options for specific cohorts) • Patient optimisation work is in development to support people with mental and physical health whilst waiting for an appointment. • Working with colleagues across WY to share best practice and learning • MSK pilots with VCS (exploring options to take the learning into other areas for long waiters) ( e.g., tailored timely interventions for people living with pain). VCS also taking on the role of health coaching (to support people to care for themselves) • Multidisciplinary team working in the community is being advanced e.g., through the work of the Proactive Care Team in the City which prevents deterioration, escalation and admission • Consultants in Trauma and Orthopaedics have advised of muscle wasting around joints; physiotherapy teams are developing resources to help people whilst they wait. • General practice - maximising virtual support versus face to face for specific cohorts and communities
76 77
Mental health and learning disabilities
77 78 Mental Health & Learning Disabilities
• Early Intervention in Psychosis (EIP) performance for the 3 month period February to April 2021 was 70.7%, remaining above the 60% target. Covid-19 initially impacted on demand, with 16% decrease in referrals, but these have now returned to pre-Covid 19 levels. The service has however, noted later presentations and increasing intensity and complexity. • There was a small month on month increase in referral rates from June through to October 2021 for Improving Access to Psychological Therapies (IAPT) services. Rates have remained at this level and this pattern has been mirrored in the number of people entering treatment over the period. However, waiting time performance remains strong, with 6 week and 18 week targets consistently being met and the recovery rate remains above the 50% national target at 56.7% for April 2021. • The Perinatal Mental Health service has seen a significant increase in referrals and complexity that is outstripping capacity. BDCFT have put temporary staff in post, increased the hours of part time staff and completed gap analysis and workforce modelling to inform the joint CCG/Trust discussions about mental health investment planning and prioritisation for 2021/22. • Increased referral rates continue to put pressure on CAMHS, and business continuity plans have been activated. Capacity has been drawn from broader Multi-Disciplinary teams (MDTs) to support allocation of duty, which means waiting times are being met. However, drawing capacity from the MDT is impacting on the broader CAMHS pathways. A range of Voluntary & Community Service (VCS) initiatives are in place and a digital offer utilised where appropriate. • Covid-19 has resulted in an increased number of inappropriate out of area placements for adult mental health services due to a combination of increasingly acute patients requiring an inpatient stay and a reduction in bed capacity to meet Covid-19 safe requirements for isolating and co-horting patients. BDCFT has worked with an IS partners to block purchase beds, with a rigorous assurance framework in place to oversee quality and maximise capacity available. 78 79 Overview of where we are at and what we need to do next
Agreed actions: • Are we really doing everything we can? Health and Care Silver June 2021 agreed to holding a system quality summit late July 2021. • Integrated Care partnership commitment to the development of Psychosocial hubs for Airedale and Bradford • Improve communication, engagement and co-production with users, patients and families ( e.g., targeted reframing of clinician/patient interaction to ensure equity and understanding) • Greater alignment between programmes to understand quick wins - e.g., Living well programme and Ageing Well, Access and Healthy Hearts Programme • Share learning of existing social prescribing schemes within primary care networks • Review extension of short term funding for specific VCS projects • Better use of multi-disciplinary team - does everyone really need to see a doctor? Offer of help from community pharmacists. • Better use of timely technology and digital solutions through system programmes e.g., the ‘Lucii’ app in the respiratory programme • The Patient optimisation work stream within the Access to Care Programme is: • Developing patient communication including relevant resources for those on waiting lists • Working collaboratively with Living Well programme offers and Healthy Minds to ensure people are supported whilst waiting • Taking best practice from other areas of the country and using resources such as NHS Apps. 79
80 Overview of where we are at and what we need to do next Ideas being considered
• Targeted support for domestic violence staff and users – review routine enquiry pilot in general practice • Review Multi Agency Support team (MAST) Project 6, carers resource, cellars trust) who help people who need a ‘little extra help’ to get out of hospital. • Improve general messaging re safe transport options • Explore how best to increased carer support mechanisms e.g., national toolkit for identification and awareness to improve signposting for local people who have a learning difficulty, dementia and autism. • End of Life pathways – tailor services to the specific needs of our communities with our communities • Use positive outcomes of the recent GP survey (July 2021) which embrace new ways of working and to focus on those areas that we can improve
80
81
NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 7
Name of meeting Governing Body Meeting date 13th July 2021
Title of report Audit of 2020/21 Annual Accounts Report author(s) Robert Maden, CFO and Auditor’s Annual Report.
Lead(s) / SRO Robert Maden, CFO Report lead(s) Robert Maden - CFO
Paper summary and/or key discussion points The 2020/21 Annual Report and Accounts for the CCG were approved by the Audit and Governance Committee on behalf of the Governing Body on the 8th June 2021 and submitted to NHS England in line with the national timetable.
These accounts will be made public along with the CCG’s Annual Report when they are presented to members at the Annual General Meeting on the 28th July 2021, and have been circulated separately to Governing Body members.
Attached is the draft Auditor’s Annual Report which summarises the findings and key issues arising from the audit of the 2020/21 Annual Accounts by KPMG our external auditor.
The External Auditor is required to provide conclusions on the following matters:
a) Accounts: Provide an opinion on the financial statements, i.e. whether they believe the financial statements give a true and fair view of the financial affairs of the CCG and of the income and expenditure recorded during the year, and whether the Accounts have been prepared in line with the Group Accounting Manual published by the Department of Health and Social Care;
b) Annual Report: Assess whether the Annual Report is consistent with their knowledge of the CCG;
c) Value for Money: Assess the arrangements in place to secure economy, efficiency and effectiveness in the CCG’s use of resources and provide a summary of the findings, including details of any significant weaknesses that have been identified;
d) Regularity: Assess whether the expenditure incurred has been applied to the purposes intended by Parliament; and
e) Other Reporting: The auditor may issue other reports where they determine that this is necessary in the public interest under the Local Audit and Accountability Act.
With respect to each of these areas, the auditor has concluded as follows:
Accounts: Issued an unqualified opinion on the CCG’s accounts (on the 15th June). This means they believe the accounts give a true and fair view of the financial performance and position of the CCG;
Annual Report: There was no significant inconsistency between the Annual Report and the auditor’s knowledge of the CCG;
81 Page 1 of 3 82 Value for Money: The auditor has not identified any matters that indicate that the CCG does not have sufficient arrangements in place to achieve value for money;
Regularity: The auditor did not identify any matters where irregular expenditure had been incurred; and
Other Reporting: The auditor did not consider it necessary to issue any other reports in the public interest.
The ISA260 Audit Memorandum reported to the Audit Committee on the 8th June 2021 also confirmed that there were no significant uncorrected audit mis-statements and that there were no significant control deficiencies.
Whilst the Auditor’s Annual Report included with this paper is in draft, there were no issues arising from the completion of the audit work after the Audit and Governance Committee meeting on the 8th June that affected the audit conclusions in the report. The final Auditor’s Annual Report will be published along with the Annual Report and Accounts on the CCG’s website. Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
[Note: please outline the key factors within this paper that will help us achieve one or more of our strategic ambitions for our population, our partnerships, our people, our leadership and what are the associated consequences and/or potential risks]
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s) The Governing Body is asked to:-
a) The Governing Body is asked to note the assurance provided by the Auditor’s Annual Report on the 2020/21 Annual Report and Accounts of the CCG. Appendices (or other supporting papers) Auditor’s Annual Report 2020/21 (Draft) 1. Auditor’s Annual Report 2020/21 (Draft)
82 Page 2 of 3 83
83 Page 3 of 3 84 DRAFT Auditor’s Annual Report 2020/21 – Draft
NHS Bradford District and Craven CCG
03 June 2021
84 85
Contents Page
Summar y 3
Accounts audit 4
Value for money commentary 7
This report is addressed to Bradford District and Craven NHS the CCG and has been prepared for the sole use of the CCG. We take no responsibility to any member of staff acting in their individual capacities, or to third parties. External auditors do not act as a substitute for the audited body’s own responsibility for putting in place proper arrangements to ensure that public business is conducted in accordance with the law and proper standards, and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively.
© 2021 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a 2 Swiss entity. All rights reserved. 85 2 NHS Bradford District and Craven CCG Summary86
Introduction Findings This Auditor’s Annual Report provides a summary of the findings and key issues We have set out below a summary of the conclusions that w e provided in respect of arising from our 2020-21 audit of NHS Bradford District and Craven CCG. This report our responsibilities. has been prepared in line w ith the requirements set out in the Code of Audit Practice published by the National Audit Office and is required to be published by the CCG alongside the annual report and accounts. Accounts We issued an unqualified opinion on the CCG’s accounts on [date]. This means that w e believe the accounts give a Our responsibilities true and fair view of the financial performance and position The statutory responsibilities and pow ers of appointed auditors are set out in the Local of the CCG. Audit and Accountability Act 2014. In line w ith this w e provide conclusions on the We have provided further details of the key risks w e follow ing matters: identified and our response on page 4-6. . Accounts - We provide an opinion as to w hether the accounts give a true and fair view of the financial position of the CCG and of its income and expenditure during Annual report We did not identify any significant inconsistencies betw een the year. We confirm w hether the accounts have been prepared in line w ith the the content of the annual report and our know ledge of the Group Accounting Manual prepared by the Department of Health and Social Care CCG. (DHSC). We confirmed that the Governance Statement had been prepared in line w ith the DHSC requirements. . Annual report - We assess w hether the annual report is consistent w ith our know ledge of the CCG. We perform testing of certain figures labelled in the Value for money We are required to report if w e identify any matters that remuneration report. indicate the CCG does not have sufficient arrangements to . Value for money - We assess the arrangements in place for securing economy, achieve value for money. efficiency and effectiveness (value for money) in the CCG’s use of resources and We have nothing to report in this regard provide a summary of our findings in the commentary in this report. We are required to report if w e have identified any significant w eaknesses as a result of Regularity We did not identify any matters w here irregular this w ork. expenditure had been incurred.
. Regularity - We assess w hether expenditure incurred is in line w ith the purposes Other reporting We did not consider it necessary to issue any other reports for w hich it w as provided. in the public interest. . Other reporting - We may issue other reports w here w e determine that this is necessary in the public interest under the Local Audit and Accountability Act.
© 2021 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a 3 Swiss entity. All rights reserved. 86 NHS Bradford District and Craven CCG Accounts87 audit
The table below summarises the key risks that w e identified to our audit opinion as part of our risk assessment and how we responded to these through our audit.
Significant Risk-Fraudulent expenditure Findings recognition As CCGs are set a statutory allocation for We performed the follow ing procedures in order to respond to the significant risk identified: the amount of expenditure that is able to be ̶ We assessed the design and operation of process level controls for the purchase ordering of goods and services and the incurred this creates a risk that there is an accrual of information at the end of the year based on those that have been receipted; incentive for management to understate expenditure in the year so that the CCG ̶ We evaluated the design of the controls in place for the CCG to engage in the agreement of balances exercise w ith other reports that the resource allocation has NHS providers and commissioners. We assessed w hether appropriate returns are made and how the CCG follow s up on been complied w ith w here accurate variances arising w ith other parties at Month 9 and Month 12. We tested w hether these controls operated as expected for reporting w ould show a breach. This could the Month 9 and Month 12 returns. We found these controls to be operating effectively; be through not completely recording accruals or through reducing the value ̶ We considered w here variances exceeding £300k had arisen from the agreement of balances exercise for payables and accrued from the cost of the services. accruals undertaken w ith other NHS providers and commissioners and inspect supporting evidence to assess the appropriateness of the balance recognised. Where differences of over £300k w ere identified, w e considered the CCG’s In the audit plan w e stated that w e also balances to be appropriate; considered there w as a risk of the CCG seeking to increase expenditure in 2020-21, ̶ Our testing also focussed on recognition of block payment expenditure. Whilst w e recognise that there is likely to be a for example if additional funding was difference betw een expected and actual expenditure relating to block payments, w e review ed individual payments to ensure available to reimburse Covid-19 related the expenditure w as in line w ith expectation per the contract and associated variations. We found no material differences costs throughout the period of audit in ̶ We inspected invoices for material expenditure, in the period follow ing 31 March 2021, to determine w hether expenditure support of the local health economy. Our has been recognised in the correct accounting period.; risk assessment did not identify this risk and therefore our risk remained focused on ̶ We selected a sample of year end accruals and inspected evidence of the actual amount paid after year end in order to completeness of expenditure in respect of assess whether the accrual had been accurately recorded; healthcare expenditure. ̶ We inspected journals posted as part of the year end close procedures that the level of expenditure recorded in order to We consider this risk w ould be most likely to critically assess whether there w as an appropriate basis for posting the journal and the value could be agreed to supporting occur through manipulating accruals at the evidence; end of the year. ̶ We compared the items that w ere accrued at 31 March 2020 by the predecessor CCGs to those accrued at 31 March 2021 in order to assess whether any items of expenditure may not have been accrued for at the year end that required recording.
Findings We did not find any issues in relation to this significant risk
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The table below summarises the key risks that w e identified to our audit opinion as part of our risk assessment and how we responded to these through our audit.
Significant Risk-Management Override of Control Findings Our audit methodology incorporates the risk of management override as a default significant risk. Professional standards require us to communicate the fraud — In line w ith our methodology, w e evaluated the design and implementation of controls over journal risk from management override of controls as significant. entries and post-closing adjustments. Management is in a unique position to perpetrate fraud — Assessed the appropriateness of changes compared to the prior year to the methods and underlying because of their ability to manipulate accounting records and assumptions used to prepare accounting estimates. prepare fraudulent financial statements by overriding controls that otherw ise appear to be operating effectively. — Assessed the appropriateness of the accounting for significant transactions that are outside the component's normal course of business, or are otherw ise unusual. We have not identified any specific additional risks of — management override relating to this audit. In line w ith our audit plan, tested the operating effectiveness of controls over journal entries and post closing adjustments. — Assessed the full population of relevant journal entries to identify journals displaying high risk characteristics. We follow ed up each of these journals in order to assess the appropriateness and accuracy of the transaction posted. Our findings — We identified journal entries and other adjustments meeting our high-risk criteria – our examination did not identify any inappropriate entries. — We did not identify any significant unusual transactions We did not identify any material misstatements relating to this risk.
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The table below summarises the key risks that w e identified to our audit opinion as part of our risk assessment and how we responded to these through our audit.
Significant Risk-Opening Balances Findings We performed the follow ing procedures in order to respond to the significant risk identified: On 1st April 2020 NHS Bradford District and Craven CCG — Confirmed that the merger has been accounted for appropriately in line w ith the requirements of the w as formed by a merger of the 3 legacy CCGs (NHS Group Accounting Manual. Absorption accounting requires that assets and liabilities are transferred Airedale, Wharfedale and Craven CCG, NHS Bradford City into the new entity at their carrying value at the time of transfer. CCG and NHS Bradf ord Dis tric ts CCG.) — Verified the accuracy of the opening trial balance and reconciled it to the three closing trial balances from the 2019-20 financial statements to confirm that they accurately represent the closing assets and The new CCG has migrated the ledgers from the three CCGs. liabilities of the predecessor organisations. This has resulted in accounting data being migrated from one ledger to another. While there are a number of risks — Review ed the consolidation of opening balances for transactions betw een the three CCGs to confirm associated w ith data migration w hich include data corruption that they have been appropriately eliminated.. and application stability risks, the most common risk associated w ith data being migrated from one system to another is that of data loss. Consequently, for our audit of the Our findings financial statements this poses a risk of incomplete or inaccurate data having been migrated over and therefore a We did not identify any issues in relation to this risk. risk of there being inaccurate ledger balances.
We also note there w ere a number of debtor and creditor balances betw een the 3 CCGs at 31 March 2020 w hich will require eliminating from the opening position.
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Introduction Commentary on arrangements We consider w hether there are sufficient arrangements in place for the CCG for each We have set out on the follow ing pages commentary on how the arrangements in of the elements that make up value for money. Value for money relates to ensuring place at the CCG compared to the expected systems that w ould be in place in the that resources are used efficiently in order to maximise the outcomes that can be sector. achieved. Summary of findings We undertake risk assessment procedures in order to assess whether there are any risks that value for money is not being achieved. This is prepared by considering the We have set out in the table below the outcomes from our procedures against each of findings from other regulators and auditors, records from the organisation and the domains of value for money: performing procedures to assess the design of key systems at the organisation that give assurance over value for money. Domain Risk assessment Summary of arrangements Where a significant risk is identified w e perform further procedures in order to consider w hether there are significant w eaknesses in the processes in place to achieve value Financial sustainability One significant risks No significant weaknesses for money. identified identified
Further details of our value for money responsibilities can be found in the Audit Code Governance No significant risk No significant weaknesses of Practice at Code of Audit Practice (nao.org.uk) identified identified
Matters that informed our risk assessment Improving economy, No significant risk No significant weakness The table below provides a summary of the external sources of evidence that w ere efficiency and identified identified utilised in forming our risk assessment as to w hether there w ere significant risks that effectiveness value for money w as not being achieved:
Care Quality Commission No current rating available due to merger of three rating previous CCGs
Governance statement There w ere no significant control deficiencies identified in the governance statement.
Head of Internal Audit Significant assurance opinion
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Financial sustainability
Description Commentary on arrangements
This relates to ensuring that the The Cov id 19 pandemic has had a major impact on the NHS and this has resulted in changes to the financial planning regime. On 17 March CCG has sufficient arrangements 2020 normal contractual arrangements w ith NHS providers w ere suspended and the NHS moved to block contract payments on account. in place to be able to continue to The value of these w as determined centrally, rather than being agreed betw een the CCG and the providers. NHS organisations w ere also provide its services w ithin the reimbursed w ith additional funding as required in order to reflect the additional costs incurred as a result of Covid-19. For months 7-12 the resources available to it. CCG allocation w as agreed from the funding envelope that w as allocated at an Integrated Care System level. We considered the follow ing Financial planning for 2020/21 commenced as part of the predecessor CCGs and an initial plan w as taken to Joint Finance and Performance areas as part of assessing Committee in March 2020. This initial plan show ed cash releasing savings of £13.8m w ere needed to achieve financial balance before the w hether sufficient arrangements new temporary regime w as introduced as a result of the pandemic. As a result of the new regime the CCG prepared a financial plan w hich w ere in place: met its statutory duties w ith appropriate assumptions. . How the CCG sets its financial We found that the budget monitoring and control processes at the CCG w ere able to identify and incorporate significant pressures into the plans to ensure services can financial plan to ensure it w as achieved. continue to be delivered; For 2021/22 the CCG has prepared a financial plan for the first half of 2021/22, w hich presents a balanced position although it has identified . How financial performance is a gap in resource of £5.5m, w hich the CCG expects to manage. This financial plan w as constructed based on appropriate local and national monitored and actions planning assumptions and these w ere set out clearly in the paper to Governing Body. identified w here it is behind While national financial planning guidance has not been agreed for the second half, the CCG has recognised the need for increased savings plan; and into the second half of 2021/22. The CCG has: . How financial risks are identified and actions to - potential mitigations and cost savings/QIPP it can make to meet some funding gaps/efficiency requirements; manage risks implemented. - arrangements to develop new schemes w here required; and - a track record of delivering savings/QIPP.
Overall given the risks and uncertainty, the relatively modest level of savings/QIPP against its resource allocation, past savings/QIPP and its track record of delivery, appropriate arrangements have been developed for 2021/22 financial planning.
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Financial sustainability
Description Commentary on arrangements
This relates to ensuring that the The longer term financial sustainability should be considered in the context of the HM Government’s White Paper for a new Health and Social CCG has sufficient arrangements Care bill w hich was published in February 2021. The proposals w hich have yet to be put before Parliament w ould see the creation of a in place to be able to continue to statutory Integrated Care System (ICS) body that w ould take on the functions of the present West Yorkshire CCGs. As these proposals are provide its services w ithin the yet to be yet to be put before Parliament w e are unable to comment on the nature and scope of the ICS or how the CCG's position w ill form resources available to it. part of it. We considered the follow ing areas as part of assessing Conclusion w hether sufficient arrangements We w ere satisfied from the w ork performed that the CCG had appropriate arrangements in place to manage and monitor its achievement of w ere in place: financial sustainability. . How the CCG sets its financial plans to ensure services can continue to be delivered; . How financial performance is monitored and actions identified w here it is behind plan; and . How financial risks are identified and actions to manage risks implemented.
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Governance
Description Commentary on arrangements
This relates to the arrangements We consider the CCG to have effective processes in place to monitor and assess risk. Strategic risks are recorded and identified using in place for overseeing the the Board Assurance Framew ork, and any identified risks are reported to the Governing Body. The Governing Body review the CCG’s performance, identifying Corporate risk register on a bi-monthly basis. Our review of the risk register found this w as sufficiently detailed to effectively manage key risks to achievement of its risks objectives and taking key The CCG have ensured appropriate scrutiny, challenge and transparency on decision making. The CCG operates under a scheme of decisions. delegation, therefore all spend is challenged and authorised at an appropriate level throughout the CCG. Spend is requested and We considered the follow ing allocated via business cases, each of w hich are scrutinised and challenged in line w ith the operational scheme of delegation areas as part of assessing In March 2020 NHSE announced revised arrangements for planning for NHS contracting and payments w hich w ere to apply for part of w hether sufficient arrangements 2020/21 in response to the Covid-19 pandemic. We review ed additional governance arrangements implemented by the CCG in w ere in place: response to the Covid-19 pandemic and found that appropriate measures w ere put in place to respond to any additional risks identified . Processes for the in light of the pandemic. These arrangements w ere presented and approved by the Governing Body in April 2020. identification and The financial planning regime has significantly changed for 2020/21. We review ed the revised governance arrangements in relation to management of strategic budget setting and monitoring. This included a review of processes for identifying and monitoring additional costs associated with Covid. risks; We found that a schedule of additional COV ID c os ts w ere routinely presented to the Finance and Performance Committee. These costs . Decision making framew ork w ere appropriately scrutinised and approved to reclaim if assessed to be in line w ith the NHSE reclaim criteria. Any reclaimable costs for assessing strategic w ere input into the non-ISFE return. Per the November 2020 non-ISFE return, the CCG recognised £15.8m Covid related expenditure. decisions; We found there to be appropriate scrutiny and challenge of the budgets and appropriate approval through the budget holders and the . Processes for ensuring Governing Body. Each budget holder w as provided w ith a monthly budget report w ithin 10 w orking days of the month end to w hich the compliance w ith law s and report relates. Discussions betw een dedicated Finance Managers and budget holders allow ed for appropriate challenge and response regulations; to adverse variances. . How controls in key areas are Conclusion monitored to ensure they are We w ere satisfied from the w ork performed that the CCG had appropriate governance arrangements in place to enable it to successfully w orking effectively. deliver value for money.
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Improving economy, efficiency and effectiveness
Description Commentary on arrangements
This relates to how the CCG We note that from the 17 March 2020 QIPP/CIP programmes w ere put on hold in accordance w ith national guidance. This w as to allow seeks to improve its systems so CCGs and providers to respond to the pandemic. For months 7 - 12 any service redesign, service extension and/or transformation w ere that it can deliver more for the to be based on provider capacity, infection prevention control (IPC) guidelines and estates. resources that are available to it. We found appropriate processes in place to ensure the CCG used information about costs and performance to improve the w ay they We considered the follow ing manage and deliver services. areas as part of assessing The CCG uses benchmarking as appropriate to identify areas w here services could be delivered more efficiently. w hether sufficient arrangements w ere in place: Governing Body monitor non-financial performance to assess whether objectives are being met via a monthly Quality and Performance Report. This report monitors a range of indicators/KPIs; provides the target measure; how the CCG is performing against each . The planning and delivery of measure; a summary of the performance and actions taken by the CCG to mitigate poor performance. All performance indicators are efficiency plans to achieve RAG rated depending on how the CCG w as performing against the target indicators. savings in how services are delivered; Conclusion . The use of benchmarking We w ere satisfied from the w ork performed that the CCG had appropriate arrangements in place to enable it to improve economy, information to identify areas efficiency and effectiveness. w here services could be delivered more effectively; . Monitoring of non-financial performance to assess w hether objectives are being achieved; and . Management of partners and subcontractors.
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Document Classification: KPMG Confidential 96
NHS Bradford District and Craven CCG
Agenda item 8
Name of meeting Governing Body Meeting date 13 July 2021 Liz Allen, Strategic Title of report CCG transition arrangements Report author Director – Organisation Effectiveness Lead Liz Allen Report lead Liz Allen
Paper summary and/or key discussion points
This paper describes the transition arrangements that have been put in place in the CCG in response to the government’s proposals published in February 2021, Integration and Innovation: working together to improve health and social care for all. Legislative changes are expected this summer. As a consequence, the statutory functions of CCGs will transfer to the West Yorkshire integrated care system (ICS) with most of these functions delegated for delivery at place in a Bradford district and Craven integrated care partnership (ICP). There is much work to be accomplished to ensure the safe and effective transfer of the CCG’s functions, people, assets and liabilities by 01 April 2022. This work is complex and there are interdependencies with related work at both the ICS and ICP levels. Reference is therefore made to work being undertaken at both system (West Yorkshire) and place (Bradford district and Craven). a) CCG transition programme board The terms of reference of the CCG transition programme board (TPB) – contained at appendix 1 – are provided for reference. They were written to describe the scope of the work of the TPB, the principles we will employ and the objectives we have set for the work in hand. Membership and attendees are listed as well as frequency, quoracy requirements and matters relevant to decision making. External and internal governance and accountability arrangements are outlined. The TPB will meet monthly to March 2022. b) West Yorkshire ICS transition transfer of functions task and finish group The aim of the project overseen by this group is to ensure robust implementation and due diligence relating to the transfer of statutory functions from CCGs and specified functions aligned to the current ICS, to the new statutory West Yorkshire and Harrogate ICS NHS Body, and to enable and support transition to agreed ways of working, including appropriate alignment and delegation to place. The project objectives are: To identify all CCG statutory transfer functions and to map functions to agreed category/level of specificity To provide a consistent framework to manage the 'close down' and transfer of CCG functions To oversee and coordinate ‘close down’ of CCG statutory functions, gaining assurance from the CCG transition programme boards To identify, agree and monitor the critical path for CCG closedown and function transfer, and to co- ordinate critical dependencies with the Future Design and Transition programme To support the implementation of shadow arrangements, if required Each CCG retains accountability for the closedown and transfer of its statutory functions, including due diligence and preparation of Transfer Orders to the new statutory organisation. The functions, including
96 97 staff and property, of all five CCGs will transfer to the same new statutory body. It is therefore thought beneficial to approach the transfer of functions in a consistent way and to a common timeline. The CCG Transfer of Functions project therefore seeks to provide a consistent framework and approach to the closedown of CCG functions, and a single coordinating point for the transfer of CCG and current ICS functions to the proposed ICS NHS Body. The project will provide assurance to the system and external partners regarding the readiness of CCG and current ICS functions to transfer to the proposed ICS NHS Body. c) WY CCG HR leads Helen Hirst and Manisha Govan (senior HR business partner) are working with other WY CCG HR leads to scope the activity required to manage the processes relevant to the transfer of the WY CCG staff. A national employment commitment was published on 16 June 2021 by NHS England and NHS Improvement. This includes a set of principles that have been developed to support and guide the impending changes and to provide a framework for a consistent approach to transition whilst enabling local implementation – recognising that ICSs are different nationally. The employment commitment confirms that all functions of a clinical commissioning group (CCG) will transfer (described as a lift and shift arrangement) to the statutory ICS and seeks to provide stability during the transition period, particularly before the establishment of the statutory organisation. As part of the ICS operating model for West Yorkshire, it is assumed that the vast majority of CCG staff will continue working in integrated care partnerships (ICPs) and therefore the ICS will be the host employer – meeting statutory and legal duties as an employer – and the ICPs will provide the day to day direction, leadership, and management of staff. d) Bradford district and Craven ICP development programme board Within the ICP development programme there are several work streams: vision and strategy, leadership and behaviour, design and delivery. The latter incorporates: operational and financial plan, data and information, clinical and professional leadership, collaborative commissioning, quality improvement and performance, assurance and accountability, governance, inequalities academy, organisation design specifics. Vicki Wallace is leading the design and delivery work – she is taking the outputs from all of the work streams with the aim of bringing them together into a coherent whole which will essentially set out the form and function of the ICP. Vicki will be working closely with those working in the ‘vision and strategy’ and ‘leadership and behaviours’ work streams as well as with Liz Allen who is leading on CCG transition given this is also an important aspect of the ‘design and delivery’ work.
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
Whilst the CCG will cease to function as an organisation at the end of March 2022, nonetheless the achievement of our ambitions for our population, partnerships, people and leadership remains the focus of our work throughout this transition period and it is essential that we ensure the safe and effective transfer of the CCG’s functions, people, assets and liabilities into the new West Yorkshire ICS and Bradford district and Craven ICP arrangements.
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss
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Recommendation
The Governing Body is asked to: 1. Receive and comment on the information contained regarding the CCG transition arrangements.
Appendices (or other supporting papers)
Appendix A: CCG transition programme board – terms of reference (approved June 2021)
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APPENDIX A – CCG TPB terms of reference
Note: this is a draft, written during development of the operating models for the West Yorkshire ICS and the Bradford district and Craven ICP – revisions will be made as these models are further advanced and other interdependencies emerge.
Terms of reference for the CCG transition programme board 29 June 2021 (v5) 1. Scope
The NHS Bradford District and Craven CCG transition programme board (TPB) will be responsible for overseeing, directing and managing the delivery of the CCG transition during 2021/22 ensuring relevant work is delivered in accordance with the government’s proposals published in February 2021, Integration and Innovation: working together to improve health and social care for all which build on the NHS’ recommendations for legislative change in the Long Term Plan.
All statutory duties and functions delivered by Bradford District and Craven CCG that will be transferred to the West Yorkshire integrated care system (ICS) are to be considered in scope.
Responding to the direction of the West Yorkshire ICS transition transfer of functions task and finish group and of the CCG Governing Body, and working with the Bradford district and Craven integrated care partnership (ICP) development programme board, the TPB will ensure the safe and effective transfer of the CCG’s functions, people, assets and liabilities.
The TPB will be guided by the vision and values articulated in our Bradford district and Craven strategic framework and by the requirements set out in these terms of reference. The TPB will have due regard to the way of working at ‘place’ as embodied in our Act as One approach, the developments associated with our ICS and ICP operating models (see appendix 2) and our updated strategic partnering agreement (SPA).
2. Principles
Foster a culture of trust, openness and transparency, including demonstrating a collective stewardship of resources for transition and ensure transition is inclusive and that our CCG staff and office holders are fully engaged, working together to make change happen Commit to working at pace to achieve rapid progress and collectively hold each other to account for delivery The CCG is a partner in the Bradford district and Craven ICP and the partnership vision is overseen by the ICP board and delivered through three health and care partnerships (HCPs) the Airedale, Wharfedale and Craven HCP, the Bradford HCP and the mental health, learning disabilities and neuro-diversity HCP.
99 100
The CCG agrees that in preparing for the transfer of commissioning functions to the ICS, and in establishing the new ICS and ICP arrangements it will continue to work towards and support the delivery of the vision as set out in our strategic framework that, by 2023, every person living in Bradford district and Craven will have the opportunities to spend more time enjoying life in the best health. Commit to the organisational change principles and HR framework articulated in appendix 3 and work in accordance with the requirements of the Equality Act (2010). 3. Objectives
(i) To provide strategic oversight, direction and management of the CCG transition (transfer of functions, people, assets and liabilities) (ii) To provide assurance to the Governing Body via the Audit and Governance Committee that due diligence has been carried out in respect of the transfer of the CCG’s functions, people, assets and liabilities (encompassing all legal and statutory obligations) to the ICS (iii) To have oversight (as a sender organisation) of the process for the provision of comprehensive and accurate staff information and to be assured of the progress in relation to TUPE, including completion of documentation to support and underpin the staff transfer orders (iv) To provide oversight, working with system and place partners, for the transfer of CCG functions, people, assets and liabilities into the new ICS and ICP operating models including clinical and managerial staffing structures and ensure these are fit for purpose (v) To hold TPB members to account to engage with partners responsible for delivery of the ICS and ICP work streams ensuring all related and interdependent TPB actions are progressed according to agreed timescales (vi) To receive assurance from TPB members that risks associated with such interdependent TPB actions relevant to the delivery of the ICS and ICP work streams are being identified, mitigated and managed (vii) To consider (as the sender organisation) whether and/or when to seek legal advice in respect of the transfer of CCG functions, people, assets and/or liabilities
4. Membership and attendees
Members Bryan Millar (chair and lay member / chair of the audit and governance committee) Ruby Bhatti OBE (governing body lay member) Neil Fell (governing body lay member) David Richardson (governing body lay member) Liz Allen (strategic director, organisation effectiveness; strategic lead for transition, link with ICS sender/receiver task and finish group and ICP development programme board) Robert Maden (chief financial officer; strategic lead for transition, link with ICP development programme board) Fiona Jeffrey (AD, organisation effectiveness; tactical/operational lead for transition) Sue Baxter (strategic head of assurance; tactical/operational lead for transition, link with ICP development programme board)
If a TPB member cannot attend, a nominated deputy can attend and vote in their place.
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Attendees Manisha Govan (senior HR business partner, link with WY ICS HR leads) Sharron Blackburn (deputy head of internal audit, Audit Yorkshire) Name tbc (staff side / trade union representative) Anna Diani (EM staff network representative) Jacinta Costello or Rachel McCafferty (WAA staff network representatives) Catherine Smith (transition programme office support) 5. Frequency and quoracy
Monthly meetings will be held from June 2021 until March 2022 with quoracy being at least four members including, as a minimum, two lay members and one director/CFO (or their nominated deputy).
6. Decision making
No decision will be taken at any meeting unless a quorum is present Members and attendees of the TPB will be required to declare any interests at the beginning of each meeting Each member will have an equal say in decisions and seek to reach consensus in line with the principles set out in section three (above) and those articulated in appendix 3 of this document Each member will comply with the existing accountability arrangements of the CCG and will make decisions which are permitted under the CCG’s scheme of delegation Where decisions need to be made outside the scope of the TPB terms of reference, these will be escalated, as relevant, to the ICS transition transfer of functions task and finish group for a decision.
7. Governance and accountability
The CCG transition programme board will: be externally accountable to the WY ICS transition transfer of functions task and finish group in matters relevant to the ICS portfolios be internally accountable to the CCG Governing Body via the Audit and Governance Committee, and report to and from (i.e. exchange information with) the BD&C ICP development programme board in matters relevant to the ICP work streams (See appendix 1)
101 102 Appendix 1: Governance – West Yorkshire ICS, Bradford District and Craven CCG and Bradford district and Craven ICP
West Yorkshire Bradford district ICS future Bradford District and and Craven design and Craven ICP Board transition CCG Council
group
Bradford District and Craven CCG West Yorkshire Governing Body Bradford district ICS transition and Craven transfer of ICP Development functions Bradford District Programme task and finish and Craven CCG group Audit and Board Governance Committee
West Yorkshire Bradford district and ICS portfolios: Bradford Craven ICP work streams: District and Corporate, Craven CCG Strategy and Vision and strategy partnerships, Transition Finance Programme Leadership and behaviour Planning and system Board improvement, Design and delivery: Clinical and professional, Operational and financial plan; People Insight and intelligence, data and communities; Clinical and professional leadership; Collaborative commissioning; Key: Quality improvement and performance; Taking direction from / reporting to Assurance and accountability; Governance; Inequalities academy; Informing and responding Organisation design specifics; (PHDU, enabling strategies)
102
103 Appendix 2: Proposed operating models for West Yorkshire ICS and Bradford district and Craven ICP (at June 2021)
103 104 Appendix 3: Organisational change principles and HR framework
Organisational change principles
Work consistently within the ambitions of the West Yorkshire Health and Care Partnership as set out in the Five Year Plan and ensure this transition brings benefit to local people and their families Ensure that our people are treated compassionately, upholding the principles of the NHS People Plan and NHS People Promise and that
employee wellbeing is our priority
Manage organisational change and transition locally in accordance
with any national frameworks, guidance and legislation Work collaboratively, and in partnership, with our trade unions Ensure that our people are treated fairly and with dignity and respect Work across our partnerships to ensure our approach is open and transparent Seek to provide security of employment for our people and ensure all reasonable steps are taken to minimise any compulsory redundancies Ensure that our people feel valued and recognised for their contribution and skills Communicate, engage and consult with our people and existing staff networks in a clear, timely, consistent and sensitive manner Strengthen and embed proactive equality, diversity and inclusion practices in our approach and implementation because we recognise the value of truly diverse representation and experience at all levels. This will include adherence to the recommendations made in the
WY&H BAME review report and WAA Network with regard to
recruitment Ensure that our functions and services are maintained during the transition Minimise disruption for our people in the way we handle the change and the transition
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NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 9
Name of Meeting date th meeting Governing Body 13 July 2021 Janet Hargreaves, Senior Head of Targeted Lung Title of report Report author(s) Strategy, Change and Delivery Health Checks Janet Hargreaves, Senior Head of Lead(s) / SRO Report lead(s) Strategy, Change and Delivery
Paper summary and/or key discussion points
Overview of the Lung Health Check programme.
Lung disease is a leading cause of premature mortality across the UK
The latest National Lung Cancer Audit published in March 2021 (NCLA 2018) shows an increase in one-year survival rates to 38.9% from 36.7% In 2017 and 31% in 2010. According to the NCLA, 49% of patients are still presenting with advanced and incurable disease with the associated impact on prognosis. This confirms an urgent need to diagnose lung cancer earlier when curative treatment is possible.
At the start of the COVID 19 pandemic, referrals for suspected Lung Cancer declined significantly. The number of two week wait referrals across West Yorkshire and Harrogate remains low at 75% of pre-pandemic levels, data including May 2021.
In 2018, three GP practices in Bradford joined a pilot ‘Tackling Lung Cancer’ developed and funded by the West Yorkshire & Harrogate Cancer Alliance (WY&HCA). The pilot demonstrated a clear stage shift towards earlier diagnosis. Stage I/II diagnoses increased from 26% in 2016 to 50% for patients diagnosed after a Lung Health Check.
The Targeted Lung Health Checks programme was announced in a press release on 8th February 2019 and is part of the NHS Long Term Plan (Jan 2019), which set out an ambition that 55,000 more people will survive their cancer – to achieve this the plan also included an ambition to increase the number of cancers diagnosed at stages one and two from half to three- quarters of cancer patients.
Following the success of the Bradford pilot, combined with high levels of deprivation, smoking and lung cancer mortality we were selected by the WY&HCA to join the National Targeted Lung Health Check Programme and offered funding as part of an expansion programme with an allocation of £5,530,196 for 4 years
The aim of the programme is to deliver Lung Health Checks to populations with the highest risk of developing lung cancer in order to identify lung cancer at an earlier stage. Evidence from areas where this service model has been piloted has demonstrated that around 65% of patients identified with lung cancer are diagnosed at stage I.
Alongside lung cancer, it is expected that the Targeted Lung Health Checks Programme will also identify other conditions, including undiagnosed COPD.
The programme will target 50 000 patients in the 55 - 74 age range, which is just under 50% of
105 Page 1 of 3 106 the total eligible population. Based on available CCG data 48% of this age cohort will be ever smokers (smokers or ex-smokers).
Approximately 24 000 patients will be invited to a Lung health Check of which is it is expected that around 11 000 will go on to have a Lung Health Check, with 6000 of these (56%) identified as high risk and offered a Low Dose CT scan.
The model predicts that approximately 260 lung cancers could be identified during the course of the project. 75% of these are expected to have an early diagnosis of grade I/II and be eligible for curative treatment.
The programme consists of two elements, primary medical care where the Lung Health Checks will be initially undertaken with onward referral for patients assessed to be at risk of lung cancer to a mobile Low Dose CT based in the local area. Bradford Teaching Hospitals Foundation Trust are to provide the Radiology and Respiratory elements of the service.
The primary medical care element of the service is allocated £880,000 across the duration of the Lung Health Check element of the project which is estimated to run until March 2023.
The funding for this will be allocated to Bradford District and Craven CCG (and thereafter in a place base allocation) for the period of the project only; there is no recurrent commitment after the period of funding ceases.
In the short term, due to COVID 19, Lung Health Checks will be carried out using a remote model either via the telephone or video link however there is an expectation that in the new financial year (2022/23) the service will revert to a face to face model, with the reintroduction of Spirometry to assess wider lung health
Lung Health Checks will be offered to patients by a letter or phone call from their GP. At the Lung Health Check, a nurse led service will assess the patients using two recognised lung health check assessment tools, which provide a 6-year risk score for lung cancer. Patients identified at a high risk will be offered a referral for a low dose CT (LDCT) scan. Scanning will be offered as close to the patient as possible via a mobile CT scanner.
It is expected that Lung Health Checks will commence in September 2021 with the first scanner visit late October 2021
It is proposed that the procurement of these health checks is undertaken by a direct contract award to the primary care collaboration in line with the overall Act as One approach. The Clinical Advisory Board (that brings together Bradford Care Alliance, Affinity Partnership, Modality Partnership, Wharfedale, Airedale and Craven Alliance) would be invited to develop a delivery proposal that meets the specification for this service within the required timescales. A single contract holder for the primary medical care element of this programme would need to be secured.
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system. Being part of this national programme will benefit the population of Bradford District and Craven, contributing to early diagnosis and associated improvements to patient outcomes.
Regarding workforce staff will be upskilled and ready for the national roll out.
The programme will offer smoking cessation support and signposting and also referrals onto other 106 Page 2 of 3 107 disease pathways as required.
Purpose assurance information decision action approve / recommend / review / consider / comment / support / ratify discuss Recommendation(s)
To approve the collaborative procurement of the primary medical care element of the Targeted Lung Checks programme. The maximum value of the contract awarded will be £880,000 and will cease in March 2023.
Appendices (or other supporting papers)
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Sean Duffy, Clinical Director, West Yorkshire and National Cancer Programme Harrogate Cancer Alliance and NHS England Helen Hirst, Chief Officer, Bradford with Craven Skipton House CCG 80 London Road via email correspondence London SE1 6LH
29 September 2020
Dear Sean and Helen,
RE Targeted Lung Health Checks Programme
Thank you for the work you are leading locally to implement the Targeted Lung Health Checks (TLHC) programme. This is a central part of our strategy to deliver the early diagnosis ambition in the Long-Term Plan, and we appreciate the energy that has been shown by your Cancer Alliance and project team to get up and running as quickly as possible.
The cancer programme recently wrote to Cancer Alliances and regional colleagues to confirm full-year funding levels for Cancer Alliances, including specific funding for Targeted Lung Health Checks. We are committed to ensuring that sufficient funding is available to you for the delivery of this project, up to your full project allocation of £5,530,196 over the life of the programme. For 2020/21, based on trajectories already submitted to the national team, we have estimated the required allocation as follows:
NHS Bradford £264 per CT scan Fixed Total with Craven to cover variable costs CCG £0 £327,778 £327,778
We have based this allocation on trajectories you have submitted to the programme. We appreciate that these may need to be updated and we will work with you to make necessary revisions over the next couple of weeks. For the avoidance of doubt, if your project delivers more lung health checks than the initial trajectory suggested, funding will be increased to reflect this.
Strategic finance will be writing out shortly to confirm the mechanism through which you will be able to access this funding for 2020/21.
We can confirm that your indicative allocation has been calculated as follows:
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• The baseline allocation calculation remains the same i.e. a ‘fixed’ allocation reflecting the central project costs for each project, plus a ‘variable’ allocation of £264 – paid based on each CT scan expected to be completed.
• TLHC figures have been calculated based on projected activity levels for this financial year. We are aware that budgets for some of the onboarding projects may need to be adjusted to better reflect the population already invited and expected follow up activity. We will work with projects to flex these amounts where necessary.
• Our commitment remains to meet the costs of running the TLHC programme independent of the number of scans actually performed. We will expect projects to make every effort to ensure that those invited attend appointments, however concerns about non-attendance rates, for example, should not be a barrier to restarting activity.
• This allocation is based on national assumptions of smoking prevalence, participant uptake of TLHCs and numbers of CT scans undertaken. We recognise that TLHC/ CT scan uptake may be higher or lower than forecast. Where this is the case, we will work with you to adjust funding allocations to reflect actual costs.
• TLHC spend will be monitored as part of the Cancer Alliance quarterly reporting process.
• Where possible any funding that you do not spend in 2020/21 will be reallocated to you in future years in line with your revised delivery trajectories. This is to ensure the overall funding envelope remains available to you to deliver the programme.
Please note we have costed your project based on an initial population size of 50,000. This is because recent CCG mergers mean the total population for your CCG is now significantly larger. We are also mindful of the need to manage demand especially as there is already another TLHC project closely located to this site.
Whilst we see this as the first phase of what will become a national rollout (subject to evaluation), funding for 2024-25 and beyond will be confirmed in line with wider NHS funding in due course.
If you have any queries, please let us know.
Kind regards, Target Lung Health Checks team Early Diagnosis – NHS Cancer Programme
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Tackling Lung Cancer Programme
Bradford Pilot 2018-2020
Evaluation Report
Hazel Taylor – Programme Manager Nasim Aslam – Project Manager (Bradford)
27 March 2020
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Foreword
Lung cancer one of the most common causes of cancer death in the UK, accounting for 21% of all cancer deaths in 2016. This is despite improvements in rates of surgery and systemic anti-cancer treatment in recent years.
The latest findings from the National Lung Cancer Audit report identified that only 37% of lung cancer patients will survive for one-year, which is unchanged from the previous year. The most recent five-year net survival figures from the Office for National Statistics for men and women in England diagnosed in 2012 (followed up to 2018) were 14% and 19% respectively. However, the most recent publication by the International Cancer Benchmarking Partnership (ICBP) showed the UK still had the lowest 5-year survival compared with the six other comparator countries.
We also know that lung cancer disproportionately affects people living in socioeconomically deprived communities and, with these groups often being harder to engage, there are inequalities in outcomes across the UK.
Historically, lung cancer has been a condition with a low profile and less clinical, research and political interest than some other forms of cancer. However, as the evidence base for action accumulates, we need to capitalise on the increasing focus to make a real difference for lung cancer patients.
Diagnosing lung cancer at an early stage can lead to more treatment options and better outcomes for patients. Data for patients diagnosed in England between 2013 and 2017 show that 88% of lung cancer patients will survive for at least a year if diagnosed at stage 1 compared to 19% for people diagnosed with the most advanced stage of disease.
Data from the National Lung Cancer Audit on the stage at diagnosis in England and Wales in 2017 showed that 57% of patients had stage IIIB or IV lung cancer at the point of presentation. At this stage of disease progression, the cancer becomes harder to treat and patient outcomes are therefore a great deal poorer than when the disease is diagnosed at stage I or II.
The aim of the Bradford Targeted Lung Health Checks Pilot was to:
Target ever smokers in the age range 55 to 75 living in areas of highest social deprivation, Smoking and Lung Cancer Mortality. Use Lung Health Checks to risk assess patients and offer a Low Dose CT scan to those at high risk – all in the community close to the patient - to identify Lung Cancer at an early stage. Promote rapid diagnosis and treatment via the local acute trust, to achieve a stage shift towards stage I/II early diagnosis of lung cancer, and enabling patients to be offered curative treatment Reduce emergency presentations of patients with late stage, stages III/IV Lung Cancer, when curative treatment cannot be offered. To prevent cancer by reduce smoking levels with an offer of Specialist Smoking Cessation Support to smokers at the point of Lung Health Check.
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Contents
Section Heading Page Number Foreword Project Foreword 2
Executive Summary Summary 5 Recommendations 7
Project Brief Governance 9 Optimising Smoking Cessation Support 10
Push & Pull Symptom Awareness Campaigns and 12 Community Engagement
Optimising the Lung Cancer Pathway 13
14 Risk Identification in Primary Care with direct to Low Dose CT scanning
Evaluation Patient Experience Survey 16 Provider Feedback 16 Outcome Data 19 High Level KPIs 28 Be Clear on Cancer Campaign 29 Return on Investment 31
Recommendations / Smoking Cessation Support 31 Next steps Lung Health Checks 31 LDCT 32 Optimal Pathways Support 32
Appendices: A Terms of Reference for Bradford Place meeting 36 B Evaluation meeting notes with Primary Care 36 C Evaluation meeting notes with Secondary Care 36 D Feedback Questionnaire from Cobalt 36 E Patient Experience Survey – Bradford CCG 36 F Community Anchor Reports 36
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Executive Summary In 2017/18 deaths from Lung Cancer were greater than any other cancer in the West Yorkshire & Harrogate Cancer Alliance area. In England deaths from Lung Cancer deaths are below those from Breast Cancer and Prostate Cancer. In order to address this inequality a decision was taken across the health and social care partnership for West Yorkshire & Harrogate to invest in a programme of work to both prevent and identify early, patients with lung cancer. Four interventions were identified as a system wide approach: 1. Smoking Cessation Working with Local Council Public Health Teams, Smoking Cessation service providers and Acute Trusts to discourage smoking and provide quit support to patients, relatives and health care staff. Ensure that lung cancer treatment is delivered in a smoke free environment. Awarded funding for smoking cessation at the point of Lung Health Check by Yorkshire Cancer Research 2. ‘Push & Pull’ Communications, Engagement & Symptom Awareness This was delivered though a number of channels, including direct engagement with patients in the pilot areas facilitated by local third sector organisations. A Be Clear on Cancer symptom awareness campaign was run across West Yorkshire & Harrogate through local media and GP Practices. Public engagement on the programme was completed through the Cancer Alliance Patient Panel and GP Practice Patient Participation Groups. 3. Lung Health Checks & Low Dose CT Scanning This was delivered in the three GP Practices in Bradford. The GP Practices were identified by their high levels of social deprivation, smoking and lung cancer mortality rates. The areas covered were located close to the ring road in north Bradford and in the Bradford East constituency:
The Ridge Medical Practice Ward: Little Horton Rooley Lane Medical Centre Ward: Bowling and Bakerend Bowling Highfield Medical Practice Ward: Bowling and Bakerend
Lung Health Checks were delivered by a primary care nurse workforce including HCAs. This was managed by the three GP Practices working together and used both agency and local practice nurses. Low Dose CT scanning was provided in the community by Cobalt, under a contract with Bradford Teaching Hospitals Foundation Trust. Electronic links with the acute trust allowed the transfer of images which were read and reviewed by the Radiology and Respiratory Teams. The service started on 29th July 2019 and by the end of January 2020, 1593 patients had received their Lung Health Check, 591 patients had received a Low Dose CT scan and had been informed of the outcome. 24 patients were upgraded on to the lung cancer pathway for further investigations and 10 patients had been diagnosed with lung cancer and had an agreed treatment plan in place. The Lung Health Check also helped identify a 3-4 times increase in new COPD diagnoses, which were passed back to the GPs for long term support in the community. There is a clear stage shift towards earlier diagnosis. Stage I/II diagnoses have increased from 26% in 2016 to 50% for patients diagnosed after a Lung Health Check. In terms of yield 1 Lung Cancer was found for every 59 Low Dose CT scans. 4. National Lung Cancer Optimal Pathway (NLCOP) The project team worked with the clinical teams on the pinch points in the system, including resolution of PET CT issues. Sharing of good practice was promoted by hosting Regional Lung Pathway Meetings and supporting work on agreed local guidelines. An additional EBUS scope was purchased for Bradford Teaching Hospitals NHS Trust, to reduce the length of the patient pathway.
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Summary of Recommendations
Smoking Cessation Support
1 It was recommended Smoking cessation at the point of Lung Health Check be replaced by CO monitoring during the Lung Health Check with very brief advice and information on quit support. 2 Smoking Cessation Adviser in the Acute Trust, it is recommended future funding is no longer required locally ‘Push and Pull’, Communications and Engagement and Symptom Awareness
3 Recommendation to seek longer term funding so that wider communications can take place Lung Health Checks
4 It is recommended that for future Lung Health Check services modelling should be based on local findings in the Bradford and Wakefield pilots. 5 Recommended to have a single primary care Lung Health Check provider for Bradford to ensure wider delivery is sustainable. Low Dose CT scanning
6 It is recommended that flow of information between the Cobalt Radiographer and staff at BRI is reviewed. 7 It is recommended that all IT processes are thoroughly tested prior to the first LHC, to ensure any IT issues can be resolved before delivery starts 8 It is recommended that there should be a 1 week gap between booking an appointment and completion of the scan. 9 Recommendation consider management support required in the future for the co- ordination of Low Dose CT Service. Radiology Reporting and Respiratory Review
10 It is recommended that a specification is developed to support formal contracting arrangements with the acute trust for any future service delivery. 11 It is recommended that a dedicated administrative team is appointed to support co- ordination of CT booking, receiving scans, Radiology, Respiratory Team and communicating results to patients. 12 The recommended Respiratory workforce is either 1wte Consultant or Fellow (with time for consultant supervision/cross-over). Optimal Lung Pathway Support
13 Optimal Pathway Group support has now been put in place by the Cancer Alliance. 14 It is recommended that the Cancer Alliance maintains support to log issues with PET CT and Surgical Capacity, raising these with Specialised Commissioning.
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Project Brief The Tackling Lung Cancer Programme was developed and funded by the West Yorkshire & Harrogate Cancer Alliance (WY&HCA) using non recurrent funding. The purpose of the programme was to introduce a system wide focus on the early identification of Lung Cancer. Four interventions were agreed and adopted for the Programme; • Optimising Smoking Cessation Support • Push & Pull Symptom Awareness Campaigns and Community Engagement • Risk Identification in Primary Care with direct to Low Dose CT scanning (LDCT) • Optimising the Lung Cancer Pathway The key intervention was the Risk Identification in Primary Care with direct to Low Dose CT scanning (LDCT). This was the main focus of the project time and resource, as it was the biggest element to deliver, and held the prospect of the most patient centred outcomes. If we found similar outcomes to the Manchester Pilot – we would see a stage shift to earlier detection of lung cancer, detection of other previously undetected lung disease in the community, detection of other incidental findings, improving outcomes for patients. The GP Practices for the pilot project were chosen by using analysis of the Index of Multiple Deprivation for areas of Bradford (located in the highest deprived ward areas), highest number of lung cancer deaths and the smoking levels of patients in the target age range group 55-75 years. The data for Bradford was provided by Public Health, Bradford Council and the decision was made by the Bradford Place meeting colleagues.
Governance The Tackling Lung Cancer Programme initially comprised two pilots to be run in the two worst areas within West Yorkshire & Harrogate measured by levels of high deprivation, smoking and lung cancer mortality. The areas identified were Wakefield Place and Bradford City, Bradford District & Airedale Place. A dedicated project manager was recruited for each ‘Place’. Projects were governed by implementing local structures to each ICS Place. Each pilot was overseen by a local Place meeting Chaired by a representative of the CCG. The Bradford Place meeting was became operational in October 2018, after the Project Manager joined the programme in September 2018. Membership included the Clinical Cancer lead from Bradford CCGs; a Patient representative; Practice Managers, a Primary Care clinician, Public Health, Acute Trust respiratory and radiography colleagues, Yorkshire Cancer Research and third sector representatives. The purpose of this multi-agency group with membership from key local stakeholders was to provide the strategic overview and monitor the pilot to ensure it was meeting its purpose, through development and implementation stages of the project (Please see attached Terms of Reference in Appendices). The meetings were held monthly co-ordinated by the Project Manager. The Chair and Clinical lead for the Place Group attended the WY&H Tackling Lung Cancer Steering Group which meets on a quarterly basis. Monthly highlight reports were produced showing progress against the programme plan.
Please see the diagram below to show the governance structure established for the pilot:
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West Yorkshire and Harrogate Cancer Alliance Board
West Yorkshire and Harrogate Lung Cancer Steering Group
Bradford Place Meeting Group
West Yorkshire & Harrogate Cancer Alliance (WY&HCA) The WY&H Cancer Alliance provided non recurrent funding for the project delivery through their Tackling Lung Cancer Programme. This was staffed by a Programme Manager and two Project Managers, one for each project area. The Senior Responsible Officer was the Executive and Clinical Lead for the Cancer Alliance, Professor Duffy. Governance oversight was provided by a regional Steering Tackling Lung Cancer Steering Group and the Cancer Alliance Board. Presentations were taken to each project area’s Health & Wellbeing Board prior to commencing work. A Stakeholder Event was held at the beginning of the programme in June 2018, and was attended by Stakeholders from each Place.
Optimising Smoking Cessation Support Each year more than 500 people die from respiratory disease in the Bradford District with an estimated 25% of these deaths preventable. With rates of early death (before the age of 75) from respiratory disease in Bradford amongst the highest in England and the second highest in Yorkshire and Humber, respiratory disease is a leading cause of dying early in Bradford District. Smoking has long been recognised as one of the main causes of preventable illness and early death and is particularly significant in the context of respiratory disease. According to annual population surveys, the proportion of adults smoking in the District at 18.9% is higher than national (14.9%) and regional (17%) averages. Smoking is more common in people in routine and manual jobs. Within this group smoking prevalence is 31.8% compared to 25.7% in England. Providing support to help smokers quit is highly cost-effective and local stop smoking services offer smokers the best chance of quitting. Smokers who use them are up to four times as likely to quit successfully as those who choose to quit without help or with over the counter nicotine replacement therapy products (DoH, 2017). In the Bradford District stop smoking support at the beginning of the pilot was provided by a team of specialists within a central service, and also via a network of providers in primary care and pharmacies.
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In order to deliver the smoking cessation support, it was important to link up with the organisations and individuals already involved in this work in the locality. Key stakeholders were: Smoking Cessation service – Public Health, Bradford Council Yorkshire Cancer Research (YCR) Bradford Teaching Hospitals NHS Foundation Trust (BTHFT)
The following initiatives were agreed locally to be taken forward:
1. Smoking Cessation at the point of Lung Health Check – Separately funded by Yorkshire Cancer Research 2. Enable patients to be treated in a Smoke free Environment
1 Smoking Cessation at the Point of Lung Health Check Public Health, Bradford Council During the implementation of the Bradford Pilot, Bradford Council’s Public Health department began its restructuring process in February 2019. The smoking cessation specialist service was no longer going to operate in its present form but be integrated into the wider Bradford Council’s Living Well service.
Yorkshire Cancer Research An application was made at a programme level to Yorkshire Cancer Research to fund Smoking Cessation at the point of Lung Health Check. In Bradford, a full-time specialist smoking cessation adviser post was identified as being required for delivery of smoking cessation at the point of Lung Health Checks to service the 3 GP Practices in Bradford. The service was provided by 2 part-time smoking cessation workers from Public Health, Bradford Council.
2 Patients Treated in a Smoke Free Environment Bradford Teaching Hospitals NHS Foundation Trust Public Health previously offered smoking cessation support on site at the Bradford Royal infirmary half a day a week. In addition, smokers were referred directly to the specialist service for support to quit; however this was inconsistent. Bradford Teaching Hospital Foundation Trust (BTHFT) is committed to achieving a smoke free hospital trust this includes the implementation of NICE guidance PH48 and PH45 to ensure access to a full range of evidence based treatment options to support quitting smoking and temporary abstinence for patients and staff. The main initiatives delivered over the project pilot within the Trust were: Funding for 2 full-time smoking cessation advisers to work in BTHFT for 12 months. Currently, no smoking specialist support offered within the Trust. Funding for the 10 CO monitors Funding for disposable mouth tubes per machine Funding for a Pop up Stop Smoking service privacy screen 8 | P a g e
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BTHFT were able to recruit to one post, a Tobacco Dependence Specialist who came into post in November 2019. He has started to see patients and is working towards having a smokefree environment in the hospital. He works alongside clinical teams to provide a totally new in-house service supporting patients to stop smoking. He is based with the Respiratory team at Bradford Royal Infirmary (BRI) but takes referrals via EPR from anywhere in the hospital.
All patients admitted to BRI who smoke will be prescribed New stop smoking service brings advice to patients’ bedside medication to tackle their addiction to tobacco and offered support to help them stay smoke-free during their stay at hospital and once they go home. Plans are already in place to offer support to staff who want to quit smoking.
Push & Pull, Symptom Awareness Campaigns and Community Engagement
The 4 initiatives under this programme outline were:
1. Patient Experience Survey
2. Direct Community Engagement to Encourage Attendance
3. Symptom Awareness – Be Clear on Cancer
4. Patient and Public Involvement
1 Patient Experience Survey a) Community Anchors Project Manager for Bradford contacted Bradford Healthwatch to see if they could support patient experience in the localities where the Lung Health Checks were taking place, replicating a similar model used for the Wakefield Pilot. Unfortunately, they were undergoing an internal restructure and did not have the capacity to support this work. The Community Anchors supported patients on the day of the Lung Health Checks as well as promoting the smoking cessation advice service offered on the day. They completed almost 200 patient surveys during this period. Bradford CCG analysed the patient experience surveys.
2 Direct Community Engagement to Encourage Attendance b) Bradford CCG Bradford CCG was approached and able to support this as they had already commissioned two Community Anchors (existing VCS engagement partners) to undertake wider engagement for them. Healthy Lifestyles Royds Both these organisations had already established relationships with both the local communities and the practices involved in the pilot. Healthy Lifestyles had already worked with Rooley Lane and Bowling Hall/Highfields Medical Practices and the Royds with the Ridge Medical Practice.
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They were involved in the wider community engagement with the localities, raised awareness and distributed leaflets from the British Lung Foundation in community venues and by attending local events and focus groups such as Library Hub, Restore Recovery College and working with Self-care champions and promoting Lung Health Checks at the Breathing Buddies Group (Recovery College), Elim Church. They also contacted other VCS partners and agencies and promoted the pilot.
3 Symptom Awareness – Be Clear on Cancer a) Campaigns The Cancer Alliance programme team supported lung cancer prevention initiatives across the West Yorkshire & Harrogate area promoting local, regional and national smoking cessation initiatives such as Breathe 2025, Stoptober. A West Yorkshire & Harrogate ‘Be Clear on Cancer’ campaign was conducted through July and August 2019 through posting advertisements on social media and regional radio stations. A poster and leaflet information pack was also sent out to all GP practices in the WY&H Cancer Alliance. Bradford Public Health Smoking Cessation service also delivered some local initiatives to support the National No Smoking Day on 13 March 2019. A promotional event was organised on the day at BTHFT for staff, patients and visitors.
4 Patient and Public Involvement b) GP Patient Reference Groups All 3 Patient Reference Group meetings were attended by the Project Manager and one of the Community Anchors. The pilot was well received and the Health Champions were keen to support the initiative prior and during the implementation stage. The Ridge PRG meeting 11 June 2019 Rooley Lane PRG meeting 25 June 2019 Bowling Hall/Highfields PRG meeting 11 July 2019
Optimising the Lung Cancer Pathway
The Tackling Lung Cancer programme team worked with Trusts on their National Optimal Lung Cancer Pathway delivery, collating current practice, sharing best practice and encouraging pathway improvement.
This was particularly supported by coordinating the Lung Cancer Clinical Meetings, arranging two meetings during the life of the project, complete with external speakers. The final meeting in October 2019 saw the meetings and work schedule transferred to the WY&HCA Optimal Pathway Team for future development.
Key stakeholders were: Lung Clinical Teams from Acute Trusts in WY&H CA area – plus York District Hospital West Yorkshire & Harrogate Cancer Alliance (WY&HCA)
From the initial pathway work EBUS was found to be a particular pinch point in some Trusts. Funding was provided by the Tackling Lung Cancer Programme for additional EBUS 10 | P a g e
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equipment at Mid Yorkshire Hospitals Trust and, Bradford Teaching Hospitals Foundation Trust in 2018. Calderdale NHSFT was provided with funding from WY&H transformation funds in 2019. This increased the capacity to deliver the pathway at each of these sites, shortening the waiting times for appointments to less than 7 days. Issues with PET scanning were collated and fed back to the specialist commissioning team.
Risk Identification in Primary Care with direct to Low Dose CT scanning This was by far the most complex element of the project, and took up the majority of the time and funding available. The model used in Bradford was different to the Wakefield Pilot. Bradford GP Practices facilitated their own Lung Health Checks with the Ridge Medical Practice taking the lead and holding the contract. Bradford District is a large metropolitan area with a population of over half a million people. Over the past ten years the population has grown steadily and is expected to continue to do so. The District has a youthful population structure and contains a rich mixture of ethnic groups and cultures. It is one of the most deprived local authorities in England and ranks 19th out of 326 Local Authority Districts. Deprivation varies greatly across the district, with wards generally around central Bradford and central Keighley appearing in the 10% most deprived wards in the country and wards located in the Wharfe Valley appearing in the 10% least deprived wards in the country. Each year more than 500 people die from respiratory disease in the Bradford District, an estimated 25% of these deaths are preventable. With rates of early death (before the age of 75) from respiratory disease in Bradford amongst the highest in England and the second highest in Yorkshire and Humber, respiratory disease is a leading cause of dying early in Bradford District.
Local Picture All 3 Practices were located in the most deprived areas of the district, including high smoking and lung cancer incidence in the target patient group which was 55-75 years old. Patients from these communities did not engage with local health services and the Practices did find this challenging. The Practices invited their own patients for the Lung Health Checks; which included following up patients that didn’t respond to the invitation letters. The Practices wrote to 60% of the patients in the first cohort and then to the remaining 40%. Patients that hadn’t been in contact from the 1st cohort of 60% were followed up again in the 2nd cohort. Key stakeholders were: West Yorkshire & Harrogate Cancer Alliance (WY&HCA) Bradford CCG GP practices: The Ridge, Rooley Lane an Bowling Hall/Highfields Cobalt Health Bradford Teaching Hospitals Foundation NHS Trust (BTHFT)
The Lung Health Checks were 30 minutes slots for each patient. The patient was seen by the Health Care Assistant (HCA) for the first 15 minutes and then by a trained nurse for the last 15
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minutes which involved spirometry testing, a lung cancer risk assessment, lifestyle advice, and for current smokers a referral of the smoking cessation service. Patients with a high risk score were offered a referral for a Low Dose CT scan and left their lung health check with appointment for a scan delivered locally on a mobile CT unit. A total of 7069 patients were invited from all 3 Practices, which it was estimated would generate approximately 2000 patient appointments.
Cobalt Health A NHS Supply Chain framework procurement process for the LDCT scanning was undertaken, with BTHFT supplies team as the lead for both Trust radiology departments. This involved a mini competition between 3 framework suppliers of mobile LDCT services, resulting in award to Cobalt Health. An essential element of the award was the rapid deployment on the mobile LDCT to sites very close to the patient LHC. For Bradford, the 2 sites for LDCT were the car parks of: The Ridge Medical Centre and Rooley Lane and Highfields/Bowling Hall which share the same car park. Cobalt arranged site surveys and the deployment of a mobile ultra LDCT scanner. Only one issue was raised: Noise nuisance complaint from a resident at Rooley Lane Car Park The service has been well received by patients at both sites, with a capacity and capability to deliver 220 LDCT scans each week. However the conversion rate from LHC to LDCT was much lower than estimated and this was not fully utilised. In future the West Yorkshire conversion rate can be used to maximise the LDCT utilisation. Weekly teleconference calls were held with Cobalt to keep in touch and discuss any ongoing issues – this was very helpful, and would be recommended in any future project.
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Bradford Teaching Hospitals NHS Foundation Trust (BTHFT)
BTHFT were engaged to deliver LDCT booking services, Radiology image management including justification, image reporting, mini MDT, and Respiratory referral for Lung related issues including Lung Cancer. BTHFT provided Cobalt access to their Radiology Information System (RIS) at the van to ensure they had an accurate worklist, could check for previous scans and provide feedback if patients did not attend. Patients were booked in by the Lung Health Check nurses and a referral was sent to BTHFT. The GP Practice managed changes to appointments and sent a final appointment list to BTHFT. The Radiology booking team added the patients to the RIS as appointments. Cobalt’s radiographer checked the RIS and confirmed demographics. Cobalt sent the images from the mobile CT scanner wireless to the cloud PACS, and then they auto-transmitted them to the PACS system. The images were moved to volumetric software to allow nodules to be measured by the radiologists. The results were then sent back to PACS, as part of the original study.
Evaluation a) Patient Experience Survey Two patient experience surveys were conducted, one after patients had received their Lung Health Check and another after they had attended for their Low Dose CT Scan. I. Lung Health Check Patient Experience Survey 175 Patients completed a patient experience survey for their Lung Health Check. 43% were women and 57% were men. The respondents split between the GP Practices was; 112 The Ridge Medical Centre 44 Bowling Hall Medical Practice 19 Rooley Lane Medical Practice Overall people were positive about their experience of their Lung Health Check saying they had been treated with compassion and were able to ask questions about their care. 98% said they would come again.
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The main areas of worry and concern were 54% were concerns about what their Low Dose CT results would be and a third of patients said they had not received information about the symptoms to look out for in the future. 88% of smokers were not interested in stopping. II. Low Dose CT Scan Patient Experience Survey 204 Patients completed the Patient Experience Survey following their Low Dose CT Scan. There was 50% split between Male and Female patients. 96% were satisfied with the booking arrangements and the majority of patients were seen between 1 and 2 weeks of their Lung Health Check. 22% were seen within a week and 23% were seen between 2 and 3 weeks. For a minority of patients there was a slightly longer wait for their scan. When patients arrived for their scan they did not have to wait and the location of the mobile was easy to access. 79% of patients found the service Good or Very Good overall and the majority of patients said they would have a scan again and were Likely or Very Likely to recommend to Friends and Family. Patients agreed that they had been treated with kindness and compassion during their scan and could ask questions before and during their scan. A few people said that they had not been given information on symptoms to look out for in the future or on what happens next. Full details of the Patient Experience Results can be found in Appendix E. b) Provider Feedback i. Primary Care An evaluation meeting was arranged with Primary Care at The Ridge Medical Centre on Tuesday 4 February 2020. The Practice Managers and Operational Managers involved in the pilot were in attendance. It was a positive meeting as they agreed overall it had been a successful pilot. By having the CT scanner at the GP Practices encouraged patients to attend for their CT scans. They agreed that Cobalt were very professional and had done site visits before the implementation process had begun. The 3 Practices worked closely with each other and patient reference groups at all 3 Practices were very supportive of the pilot and what it was aiming to do. The clinicians at the Ridge are hoping to share the learning from it during their educational sessions especially in connection with new COPD diagnoses. However, there were issues during the pilot which caused delays and pressure on Primary Care. Examples discussed included the referral paperwork, the referral process did not run smoothly and will need adjustment in the future. It was recommended that more time was needed between the Lung Health Check and the Low Dose CT Scan. As the Practices did not have enough capacity to release their own nurses for the Lung Health Checks, they recruited nurses from an agency which were not always reliable. As the pilot was short-term, the practices struggled to employ staff and train them. The smoking cessation advice service was not fully utilised. The practices sent out text messages to all the patients that were invited for Lung Health Checks informing them of the service.
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Recommendations for the future included the suggestion that the Lung Health Check service could be run by a GP Federation rather than individual GP Practices. The Wakefield pilot used this model and it was very effective in the delivery of the Lung Health Checks. Leading up to the last few weeks of Lung Health Checks, practices struggled to book patients in for Lung Health Checks. They telephoned patients directly booking them in, but they didn’t always turn up and there was a large number of cancellations. Patients cancelling appointments is an issue locally within these GP Practice populations. A copy of the notes taken at the Primary Care Feedback Meeting is included in Appendix A.
ii Acute Trust (BTHFT) An evaluation meeting was arranged with the Trust at BTHFT on Wednesday 5 February 2020. Respiratory Physician, Radiology, Operational Managers and IT were in attendance. The relationship with Primary Care and the Acute Trust was good and issues that arose were dealt with immediately. The communication with Practice Managers was good. BTHFT had purchased volumetric software, Veolity, which worked well but needs further integration with the PACS system. The respiratory team had employed a Clinical Fellow to undertake the follow-ups. This worked well and he saw approximately 70 patients in clinic. There were 73 patients identified as having nodules. Some of the challenges they faced related to the referral process from Primary Care. The referral information was not always sent to the Trust on time and on occasion was not accurate as it differed from the appointment lists sent in. In some cases insufficient time was allowed between the Lung Health Check and Low Dose CT Scan. However, the process improved during the second cohort of patients that were seen. It was recommended that the referral process is reviewed before any future service is delivered. There was some delay caused by corrupt images arriving from the Cobalt cloud. BTHFT had to re-scan one patient because of a corrupt image. Overall, more administrative resources would be needed for any future service and sufficient time allowed to test new processes. A project and a programme management team would be required again. See Appendix B for the notes of the meeting.
iii Bradford Smoking Cessation Service, Public Health An evaluation meeting was arranged with the Smoking Cessation Service, Public Health, Bradford Council on Tuesday 21 January 2020. The Head of Public Health and the smoking cessation advisers were in attendance. The smoking cessation advisers felt that all staff involved in the project (including scanning team) should have been trained in giving ‘Very Brief Advice’ and have knowledge of Public Health guidance on the use of E-cigarettes. https://www.ncsct.co.uk/publication_very-brief-advice.php
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They also noticed that there was a lack of awareness amongst agency staff and from the Community Anchors about the roles of the smoking cessation service. It would have been preferable to have a meeting for all staff prior to the start of the programme. She recommended having carbon monoxide testing to be included in the LHC to verify smoke free status. There was a large proportion of ex-smokers compared to smokers having a Lung Health Check. This led to periods of no activity for smoking cessation team. Patients reporting E-cigarette use, the cessation advisors queried whether these patients had been asked to confirm that they had quit tobacco completely? The smoking cessation advisors were not sure if the screening formula took account of patients understating their smoking habit? Some patients admitted to this. What would be useful in future planning is to include the details of the local stop smoking service as a footnote on all written correspondence sent out to patients. However, there was some positive feedback given from patients. Patients who did take advantage of the service had been very positive indeed and were grateful they were on site. Some feedback forms have been sent to Lisa Trickett from Yorkshire Cancer Research.
iv BRI - Tobacco Dependence Specialist, Respiratory A teleconference call was made on 5 March 2020 with the Tobacco Dependence Specialist recruited in November 2019 for 12 months. Full-time at the Trust, the Tobacco Dependence Specialist is working jointly with clinical teams to provide a totally new in-house service supporting patients to stop smoking. He is based with the Respiratory team at Bradford Royal Infirmary (BRI) but takes referrals via EPR from anywhere in the hospital.
All patients admitted to BRI who smoke will be prescribed medication to tackle their addiction to tobacco and offered support to help them stay smoke-free during their stay at hospital and once they go home. There are plans to offer advice and support staff who wish to quit smoking too.
Some future work planned at the hospital is: Looking at maternity unit and developing plans on how to support patients who smoke in the maternity unit. Increase referral rates for lung cancer and respiratory clinics. Also include adding Upper G.I and head and neck cancer patients. This includes attending the cancer support centre on a monthly basis. Promoting the smoking cessation service to all patients within the hospital trust. Working with clinical staff (CNS) Promotions on a fortnightly basis in the hospital foyer to raise awareness of the service. Actively using EPR to look for smokers on all wards throughout BRI. Also receiving referrals form EPR To contact patients at home if they are discharged before they have been seen. To raise awareness via the hospital communication channels Start group sessions for patients at the hospital
v Cobalt – Provider of Low Dose CT Mobile Service
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A questionnaire was sent to Cobalt to complete in relation to their experience of delivering a service to both pilots. They appreciated that the Bradford pilot delayed their start date and this helped to ensure that processes were in place including the set-up of IT before implementation. Initial connectivity discussions with the Acute Trust were taken very seriously and the Trust spent time working through the IT and Radiation Protection issues involved. This ensured that a fully connected service as in place from the first day of the service. Although Cobalt did site visits prior to starting in consultation with the Practice Managers, they were concerned that the sites identified in 2 GP car parks were ‘a little tight’. However, they appreciated that these were ideal sites for patients but felt that further community engagement may have helped to overcome some of the issues around space. In terms of the booking process, Cobalt felt that there were too many people involved in this which often complicated matters. They also mentioned the image transfer sent to the Trust worked well as they were sent directly to the Trust’s PACS and the radiographers were able to check they had been delivered. They were able to post process the patients in CRIS. The Cancer Alliance Programme Team facilitated regular weekly teleconference meetings with Cobalt to ensure regular communication was in place to identify any risks or issues that may emerge during the pilot period. Cobalt welcomed this regular communication channel and felt supported throughout the pilot. See Appendix C for the completed questionnaire.
c) Outcome Data
I Lung Health Check
Flow chart of the Patient Pathway
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The following data was collated by Primary Care for the Lung Health Checks:
Lung Health Check Appointment Data
Data Item Format Result
Number of Patients Invited Number 7069 Number of LHC Booked Number 1948 Number of LHC completed Number 1593 % appointment Utilisation Number % 82% Number of DNA’s Number 128 % DNA Rate Number % 7% Number of Cancellations Number 227 % Cancellation Rate Number % 12% Number of smokers Number 538 % Number of smokers Number % 28%
The GP Practices tried to encourage patient attendance for the Lung Health Checks by ringing them and sending a text message 24 hours before the appointment. Unfortunately, it was difficult to engage with patients towards the end of the programme and encourage them to attend the Lung Health Checks. The number of patients having a Lung Health Check fell short of the original estimates at the beginning of the pilot due to a large number of cancellations. Only 1593 appointments were completed out of the 1948 initially booked.
Lung Health Check Appointment Outcomes
Data Item Format Result Number of LHC completed Number 1593 Number of patients having Lung cancer risk Number 684 >1.51
% of patients having Lung cancer risk >1.51 Number % 43%
Number of patients signposted to GP Number 59 % of patients being signposted to GP Number % 4%
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46x New diagnosis of COPD 7 x patients high blood pressure Reasons for signpost to GP Text 2 x patients had low SATS 4 x patients had shortness of breath whilst carrying out Spirometry
Number of patients having Spirometry Number 1063
% of patients having Spirometry Number % 67% Number of LHC patients who currently Number 538 smoke % of LHC patients who currently smoke Number % 34%
Patients with family history of Lung Cancer Number 15 Patients with family history of Lung Cancer Number % 1%
The Lung Health Check Appointment outcomes data above shows the following:
684 (43%) of the LHC participants were identified as having a high risk for lung cancer using the PLCOm 2012 risk tool. This tool is adapted from the Brock University tool, as used in the Nelson trial.
59 (4%) of the patients were signposted to the GP practice for further support or treatment in primary care. These were identified as being for: a) 46 new COPD patients b) 7 patients had abnormal high blood pressure c) 2 patients had low SATS d) 4 patients had shortness of breath whilst carrying out Spirometry
COPD Findings from Lung Health Checks
New diagnoses th th th th th th th th th th 29 July – 6 29 July – 6 29 July – 6 29 July – 6 29 July – 6 th Practice Average of COPD 29 July Dec 2014 Dec 2015 Dec 2016 Dec 2017 Dec 2018 – 6th Dec 2019
Bowling Highfield 21 28 13 19 11 18 47 (x2.5) Rooley Lane 5 18 2 7 44 15 64 (x4) The Ridge 13 8 13 21 18 15 13 (x1)
The COPD data above shows:
Patients registered with Bowling Hall/Highfields Medical Practice showed a 2.5 times increase in detection rates Patients at Rooley Lane Medical Practice showed a 4 times increase in detection rates Patients at The Ridge Medical Practice showed a no increase in detection rates
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The 46 new patients identified with COPD will be treated in Primary Care.
II Smoking Cessation
Smoking cessation support was provided with funding from Yorkshire Cancer Research to ensure that all LHC patients who were current smokers were provided with immediate support/encouragement to quit. This was delivered by colleagues from Bradford Smoking Cessation service – Public Health, Bradford Council.
The outcomes from the Bradford Smoking Cessation service (SCS) were:
Smoking Cessation Data
Data Item Format Result Number of LHC completed Number 1593 Number of smokers Number 538 Number of smokers accepting referral to SCS Number 62 Number % of smokers accepting referral to SCS 12% % Number of smokers whose risk score >1.51 Number 364 Number % of smokers whose risk score >1.51 68% % Number of smokers referred to SCS setting a quit date Number 47 Number % of smokers referred to SCS setting a quit date 76% % Number of smokers referred to SCS achieving quit at 4 weeks Number 16 Number % of smokers referred to SCS achieving quit at 4 weeks 26% %
The use of the smoking cessation adviser’s time was compromised by the relatively low number of smokers, approximately 62 (12%) out of the 538 smokers attending for a Lung Health Check. Only 16 (26%) of these smokers achieved a 4 week quit.
However the offer of a Lung Health Check did hit the target population as 538 (34%) of the patients attending a lung health check were smokers. The prevalence level rate across the
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three GP Practices ranges from 23% to 25% in the age cohort. But as reported in the Patient Experience Survey the majority of smokers did not want to quit.
This lack of activity was mitigated during the project by offering smoking cessation support to other patients registered at the practice, and by delivering the follow-up patient sessions in practice.
The uptake for this smoking cessation support at the point of Lung Health Checks was low for both pilots, and would need to be delivered differently in any future Lung Health Check service.
III Low Dose CT Scanning and Radiology Reporting
The radiology reporting was planned to be completed within 3 weeks of the LDCT to ensure that all reporting had been completed prior to the next Low Dose CT Mobile visit, which were scheduled for every fourth week in the Lung Health Check cycle.
Flow chart of the Patient Pathway
Low Dose CT Patient attends Low Result will be Patients with a Appointment made Dose CT communicated to postive result will be by Lung Health Appointment the patient seen in hospital Check Nurse
Low Dose CT Data
Data Item Format Result Number of LHC completed Number 1593 Number of patients having Lung cancer risk >1.51 Number 684 % of patients having Lung cancer risk >1.51 Number % 43% Number of high risk score patients referred for LDCT Number 684 % of high risk score patients referred for LDCT Number % 100% Number contraindicated for LDCT Number 10 % contraindicated for LDCT Number % 1% Number Declined LDCT Number 0 % Declined LDCT Number % 0% Patients with family history of Lung Cancer Number 5 % Patients with family history of Lung Cancer Number % 0% Number of LDCT Booked (appointments used) Number 674 Number of LDCT completed Number 591 % appointment Utilisation Number % 88% DNA Rate Number 33 % DNA Rate Number % 5% Cancellation Rate Number 50 % Cancellation Rate Number % 7%
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In the table above the LDCT data is showing the following:
a) From the Lung Health Checks, 684 patients (43%) were identified has having a lung cancer risk score greater than 1.51 and were identified as high risk b) All high risk score patients were referred for LDCT c) 684 appointments were booked for LDCT d) 591 LDCTs were completed. Although 684 appointments were booked for LDCT, 89 appointments were not required. This was because justification took place within the acute trust and some patients were excluded at triage either because they had a previous CT in last 12 months, or for medical reasons. Some patients did not attend their appointment.
The conversion rate for LHC to LDCT was found to be lower that Manchester (55%), which was used in the modelling tools. Bradford showed a 37% conversion rate, which when checked was similar to the Leeds and Wakefield projects. It is recommended that the local conversion rate is applied to any future Lung Health Check service to ensure a more efficient usage of the LDCT mobile unit.
Following the Low Dose CT scan the BTHFT Radiology Team read and reported against the LDCT scans. This data is shown in the table below:
Pathway - Radiology Reporting
Data Item Format Result Notes Number of LHC completed Number 1593 1 patient had to be Total number of LDCT Number 591 rescanned at hospital due reported to corrupt files
% of LHC have LDCT reported Number % 99%
Number of Negative LDCT Number 444 LHC1 (LHC1) % of Negative LDCT (LHC1) Number % 75% % of scans reported Number of Nodules (LHC2) Number 73 LHC2 % of Nodules (LHC2) Number % 12% % of scans reported Number of Cancers (LHC3) Number 24 LHC3 % of Cancers (LHC3) Number % 4% % of scans reported Number of Further Number 50 LHC4 Investigation (LHC4) % of Cancers (LHC4) Number % 8% % of scans reported Number of significant findings Number 10 (not cancer) % no significant findings (not Number % 2% % of scans reported cancer)
LHC 1 Negative Findings LHC 2 Nodules Found (3 month or 12 month FU scans booked) LHC 3 (upgraded to cancer pathway – cancer has been excluded in some)
LHC 4(will be seen in clinic – some already have- not all patients are being seem in clinic, they would be classed as significant other findings)
16 have been excluded as “not lung cancer”. 10 of these are for 3 month FU scan, 2 for 6 6 definite Lung Cancers and 2 likely (but not engaging with investigations)
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Radiology Reports
Cobalt passed the CT images to BTHFT radiology for reporting. Reports were scheduled to be completed in the 3 weeks, prior to the next mobile CT visit. The Trust achieved this.
However, the Trust did experience a few challenges at the beginning of the process, with corrupt widgets and difficulty uploading the reported scans in to the volumetric software. This cause a minor delay to the respiratory review and follow up until the issue was resolved. One patient had to be re-scanned due a a corruption issue which could not be resolved.
Radiology Reporting Outcomes; 24 Patients were recommended for upgrading to the Lung Cancer Pathway 73 Patients were identified with nodules 10 Patients had other significant findings
IV Respiratory Review & Lung Cancer Stage
The respiratory review and lung cancer staging was delivered by the BTHFT respiratory team, with onward surgical/radiotherapy treatment delivered by Leeds teaching Hospitals NHS Trust (LTHT).
Respiratory workforce required was either 1 full-time consultant or a Clinical Fellow with time for consultant supervision/cross-cover. Bradford Acute Trust employed a Clinical Fellow for 6 months to support delivery. Patients upgraded to the cancer pathway or requiring additional diagnostics for other conditions were seen by the Fellow in clinic with supervision by the respiratory consultant.
The Respiratory team also emphasised the importance of having administrative support to send out letters to patients. Existing administration staff were used to support the pilot, and were paid over-time to cover the work. Additional staff would have to be recruited for any future Lung Health Check service.
Shortly after the start of the project the Cancer Alliance met with the LTHR thoracic surgery manager and shared patient number predictions. This capacity was agreed and colleagues in specialist commissioning were informed of the potential activity.
Patients were reviewed and worked up with BTHFT respiratory physicians as they were reported as positive LDCT. Negative LDCT reports were returned to the GP Practices for communication to patients by letter. Negative patients are to be invited for a 24 month follow up scan by the Trust. This follows the pathway now published by The National Targeted Lung Health Check Programme in March 2019.
Nodule patients were managed according to the British Thoracic Society Guidelines for the management on lung nodules, some having 3, 9, and 12 month follow up scans to determine any growth of the nodule.
Patients with a Lung Cancer diagnosis were upgraded to a consultant treatment pathway, for further diagnostic tests. Once upgraded they are managed according to national cancer standards, including the 31 day referral to treatment standard.
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Linking with the Radiology Reporting Table above, the Respiratory Team reported that:
591 LDCT scans were reported 73 nodules found 444 (75%) scans were reported to be negative 147 (25%) scans were reported to be positive 73 Patients were identified with Nodules 24 Patients were immediately upgraded to the Cancer Pathway 10 including 1 likely Patients were diagnosed with Lung Cancer (from the 24) 50 Patients were seen in clinic for further investigations (not cancer) 10 out of the 50 patients were identified with significant other findings (not cancer)
Patient Outcomes – Stage & Treatment The main focus of this programme was to increase the early detection of lung cancer enabling more patients to have curative treatment resulting in lives saved. In the Bradford Pilot 10 Lung Cancers were diagnosed after the initial Low Dose CT was completed on 591 patients. 5 Patients were diagnosed with Stage I Cancer
Lung Cancer Stage 10 lung cancers were identified
5 patients Stage 1 1 patient Stage III 2 patients Stage IV 2 patients Stage Unknown (1under investigation, 1 patient declined further investigation)
Evidence of Stage Shift Previous work from the Manchester pilot has shown that the proportion of patients diagnosed with early stage lung cancer at Stage I and II following a Lung Health Check was 80% where their normal rate of detection was 20% of the total cancers found. This was hailed as a paradigm shift towards early detection and an increase in the number of patients who could have curative treatment ( https://www.mhcc.nhs.uk/news/north-manchester-pilot-quadrupling- lung-cancer-early-diagnosis-rates/ ).
In the Bradford pilot 50% of the cancers were detected at Stage I/II. 30% of the cancers were detected at Stage III/IV. This is a clear stage shift from the normal range identified in 2016 as 26% at Stages I/II and 65% at Stages III/IV. See Graph below.
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In terms of yield 1 Lung Cancer was found for every 59 Low Dose CT scans.
Treatments
Two patients declined further intervention following their initial diagnosis, one of these patients had to be categorised as a likely cancer as they refused further diagnostic tests. Data from the Respiratory Team identified the following treatment outcomes for the 24 patients upgraded on to the Lung Cancer Treatment Pathway;
Number of Treatment Description Stage Patients 14 Patients had Lung Cancer excluded N/A 2 Suspected and to have a f/u CT in 3mths N/K 3 Surgical Resection Stage I 1 Chemotherapy Stage I 1 Surgery with adj. Chemotherapy Stage IV 1 Surgery with adj. Chemotherapy +/- Stage I Radiotherapy 1 Awaiting Treatment Plan – Patient not Stage III engaging 1 Awaiting Further investigations – Not Stage IV tolerating CT
Other Significant Conditions (Not Cancer)
10 Patients were identified as having Other Significant Conditions. Unfortunately these were not coded, and no further detail can be provided.
e) High Level KPIs
i. 1 Year Survival Rates
Diagnosing lung cancer at an early stage can lead to more treatment options and better outcomes for patients. Data for patients diagnosed in England between 2013 and 2017 show that 88% of lung cancer patients will survive for at least a year if diagnosed at stage I, compared to 19% for people diagnosed with the most advanced stage of disease, stage IV. It is too early to see any effect on the 1 year survival rate for patients from the pilot, however according to the CRUK data; the expected 1 year survival rate for newly diagnosed Lung Cancer is currently 30.4%.
To increase survival rates patients need to be diagnosed at an earlier stage. Currently in West Yorkshire only 23% of patients with Lung Cancer are diagnosed at stage I. However the Bradford Pilot has demonstrated that Lung Health Checks can increase the number of patients diagnosed early by achieving 50%. This proportion may increase as patients with nodules under go their follow up scans. . The NELSON trail has suggested that 2.3% of follow up scans result in a lung cancer diagnosis. 73 patients are currently on the nodule follow up pathway.
The Cancer Alliance will continue to monitor 1 Year Survival rates for Lung Cancer to observe any impact the lung health check programme may make.
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The current rate of emergency presentation with Lung Cancer in West Yorkshire is 30.4% of cases. Cases presenting in A&E are usually those where there has been no GP intervention, and medical advice has only been sought when breathing difficulties are experienced. This group of patients have a very poor prognosis, as they are usually in late stage disease, Stage IV, with a 20% survival at 1 year.
Proactively seeking Lung Cancers at an early stage should reduce the number of patients who present as an emergency. However this may take several years to become apparent.
iii. 2 Week Wait Referrals
It would be expected in the longer term that 2WW referrals from the practices in the project would be reduced.
It was also anticipated that the Symptom Awareness Campaign might increase the 2 WW referrals. However no impact of the West Yorkshire and Harrogate 2ww rates has been observed to date. But as there is a three month lag in data being available and a potential delay form the time of the campaign this may yet emerge. See next section.
e) Analysis of the “Be Clear on Cancer “campaign The WY&HCA supported a number of local authority led smoking reduction cessation campaigns including Breathe 2025, Don’t be the One (January 2019) and Stoptober (October 2019). The WY&HCA Lung Team delivered a targeted Be Clear on Cancer campaign in (July/August 2019). This was a co-ordinated campaign produced for the Alliance by Redwall Creative to deliver the message via Heart Radio and Social Media messaging, and the Cancer Alliance producing a GP practice pack for each GP in West Yorkshire & Harrogate including: A4 posters A3 posters Tri Fold leaflets All of these carried the Public Health England posters/leaflet content for Lung Cancer. We targeted the “cough campaign” message in the summer, when GP practices should not have been seeing patients with these symptoms in any number – and so patients exhibiting these symptoms were at higher risk of having Lung Cancer. Heart Radio delivered 46 x 30 second adverts across the full 7 days of the initial campaign, resulting in 435,832 reach with the audience hearing the advert on average 5.7 times. The social media reach was delivered using Facebook, with a reach of 573,190 with 3,799 clicks on the message. This was also backed up with information on the West Yorkshire & Harrogate Cancer Alliance Facebook and Twitter accounts. The timing of this delivery was also to support Lung Health Checks being delivered in Bradford and Wakefield from June through to December. 2WW numbers across West Yorkshire & Harrogate are currently being monitored for the identification of any discernible impact, but no impact has been seen to date in in this data.
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f) Return on Investment a. Smoking Cessation at the Point of Lung Health Check – Total costs for this service were £27,094. The low activity rate meant that the return on investment was low at 62 referrals and 16 quitters the cost per referral was £437 b. Targeted Lung Health Checks and Low Dose CT Screening – The total Costs for this service was £529k. This yielded 24 patients upgraded to the Lung Cancer pathway with 8 confirmed cancers after further diagnostic investigation. c. 168 Patients gained a health benefit from the Lung Health Checks; i. Stopped Smoking - 16 ii. COPD New Diagnoses – 46 Patients iii. Other Patients in Primary Care – 13 Patients iv. Confirmed Cancers – 8 (10 suspected - 2 patients declined further investigation) v. Patients with nodules – 73 vi. Other Significant Findings – 10 Total return on investment against 168 patients with a potential health benefit gained was; Total Return on Investment was £556k/168 = £3,310 per patient with a health benefit gained 5 of the 8 patients diagnosed with Lung Cancer have been referred for treatment with a curative intent. Their lives have been saved. Further Lung Cancers may be identified, and lives saved, as patients with Lung Nodules are reviewed or as a result of the 24 month scans. The cost of the follow up scans has not been included in the calculations above.
Conclusions, Recommendations, and Next Steps The Bradford Lung Health Checks Pilot has now come to an end and this evaluation has been designed to look at what worked well and where improvements could be made in any future delivery of a Lung Health Check service. The model delivered was of Lung Health Checks delivered in Primary Care. Patients identified as being at high risk of Lung Cancer were offered a Low Dose CT scan, with their appointment being booked during the consultation. A Mobile Low Dose CT service was delivered in the community and patients were able to attend within four weeks of their Lung Health Check. The mobile CT had IT connectivity with the Bradford Teaching Hospitals Foundation Trust and were able to send images directly into the radiology system. The acute trust teams provided radiology reporting and respiratory review to discern onward treatment/monitoring. Patients requiring further review were contacted directly by the trust, and patients with a negative result were informed by letter by their GP. This delivery model was shown to work, and with further refinement of the patient pathway, could be used in an expanded model to target the whole CCG targeted population, subject to local workforce capacity. This model is only viable for patients who currently are or have been smokers (ever smokers), aged 55-75, in line with national recommednations.
Smoking Cessation Support
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Smoking Cessation Adviser in the Acute Trust – funded for 12 months. There are other national initiative supporting this work through CQUINs and therefore it is recommended future funding is no longer required locally. The delivery of Smoking Cessation support at the time of the LHC was not a very effective ‘value for money’ resource. The uptake of this service was very poor. It has been recommended that it would have been more cost effective to refer patients to the existing GP/local service with a target contact date. The measurement of CO in the LHC was suggested by the smoking cessation worker as a “trigger” for referral to Smoking Cessation support. It is recommended that CO monitoring is included in future Lung Health Checks and that staff are able to give very brief advice and refer on to local services with a contact target d
‘Push & Pull, Symptom Awareness Campaigns and Community Engagement ‘Push/Pull’ communications were put in place to encourage patients to book a Lung Health Check. In Bradford direct awareness raising was more difficult as it was not desirable to raise expectation across the whole area due to lack of confirmed future funding. Recommendation to seek longer term funding so that wider communications can take place
Lung Health Checks The modelling tool used an estimate of 55% of Lung Health Check patients with a High Risk of Lung Cancer, based on outcomes from the Manchester pilot. In Bradford only 37% of patients were found to be at high risk of Lung Cancer. This resulted in the under use of the Low Dose mobile CT capacity. It is recommended that for future Lung Health Check services modelling should be based on local findings in the Bradford and Wakefield pilots. The 3 GP Practices worked well together but they believed there was a need for a dedicated lung health check team, due to the volume of patients who need to be seen and high level of patients cancelling their appointment. The Practice Managers suggested that in the future it may be better to deliver the service through a GP Federation rather than individual Practices. This would provide better continuity when the service when moving on to serve new GP Practices. Recommended to have a single primary care provider for Bradford. ate.
Delivery of Low Dose CT scanning It is recommended that flow of information between the Cobalt Radiographer and staff at BRI is reviewed. Sharing information on patient lists was a suggested area for improvement It is recommended that all IT processes are thoroughly tested PRIOR to the first LHC, to ensure any IT issues can be resolved before delivery starts. This would include testing image transfers from the Cloud. The first batch of images had been corrupted and there was more administrative tasks than expected in connection with these image transfers. It is recommended that a specification is developed to support formal contracting arrangements with the acute trust for any future service delivery. This will ensure that roles and responsibilities are clear and agreed in writing between all partners engaged to deliver the service. 28 | P a g e
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It was found that there was insufficient time between booking a patient in for a LDCT scan and the scanning appointment. It is important that sufficient time is allowed for the vetting process (justification) to take place, ensuring there is no reason the patient cannot have a scan. Justification is part of the legal requirement regarding the management of patients having a scan. It is recommended that there should be a 1 week gap between booking an appointment and completion of the scan. Additional administration time/additional staff needs to be factored in, as secretaries were required to send out template letters to patients. It is recommended that a dedicated administrative team is appointed. The recommended Respiratory workforce is either 1wte Consultant or Fellow (with time for consultant supervision/cross-over). The appointment of a Fellow for 6 months worked well for the pilot. Co-ordination of the Mobile CT had been covered by the Cancer Alliance Programme Team. Further support will be required for the 24 month scans in 2021/22. Recommendation consider management support required in the future.
Optimal Lung Pathway Support Regional Pathway meeting are effective in bringing together Clinicians, Nurses and Managers to support the achievement of the National Lung Optimal Cancer Pathway (NLOCP) in Trusts. A Lung Cancer Optimal Group has now been put in place by the Cancer Alliance. Cancer Alliance support facilitated the development and agreement of Local Guidelines for the Management of Lung Cancer, and to get them adopted across West Yorkshire and Harrogate. These are now in place. Cancer Managers appreciated support provided by the Cancer Alliance in logging issues in the pathway around PET-CT access and surgical capacity and raising them with Special Commissioning. It is therefore recommended that the Cancer Alliance maintains this work within the revised structure.
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Appendices
Appendix Item Page A Terms of Reference for Bradford 35 Place meeting 35 B Evaluation meeting notes with Primary Care 35 C Evaluation meeting notes with Secondary Care 35 D Feedback Questionnaire from Cobalt 35 E Patient Experience Survey – Bradford CCG 35 F Community Anchor Reports
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Appendices: Appendix A Terms of Reference for Bradford Place meeting
TOR Bradford Place Tackling Lung Cancer - V2.docx
Appendix B Evaluation Meeting notes with Primary Care – 4 February 2020
Evaluation meeting notes with Primary Care 04.02.2020 - Final.docx
Appendix C Evaluation Meeting notes with Secondary Care – 5 February 2020
Evaluation meeting notes with Secondary Care 05.02.2020 - Final.docx
Appendix D Feedback questionnaire from Cobalt
Cobalt Evaluation Questions Feedback.docx
Appendix E Patient Experience Surveys
CT Scan survey Lung Health Check evaluation report.pptxEvaluation Survey report.pptx
Appendix F Community Anchor Reports
2nd Monitoring. 1st Monitoring. 2nd Monitoring. Community EngagementCommunity Highlight Engagement Report PeriodCommunity Highlight 2 HLS.docx Engagement Report Period Highlight 1.docx Report Period 2 Royds.docx Appendix ?? Outcomes and Stage
Outcomes & stage.xlsx
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Business Case
Targeted Lung Health Checks for Bradford and Craven CCG
Purpose and Proposal
This paper outlines the background to the National Targeted Lung Health Check (TLHC) Programme and the resources available for delivery. It demonstrates how being part of this national programme will benefit the population of Bradford and Craven, contributing to early diagnosis and associated improvements to patient outcomes. It also describes the proposed approach to the patient pathway, the financial model for the programme and the proposed next steps in terms of procurement of the services.
Introduction
Lung disease is a leading cause of premature mortality across the UK. Lung cancer remains the biggest cancer killer across the UK for both men and women, with more than one in five cancer deaths (21%) attributed to lung cancer. Between 2016 and 2018 there were over 35,000 deaths from lung cancer in the UK each year which equates to around 96 per day.
The latest National Lung Cancer Audit published in March 2021 (NCLA 2018) shows an increase in one-year survival rates to 38.9% from 36.7% In 2017 and 31% in 2010. Although this is moving in the right direction progress this remains significantly behind the national average for other common cancers. According to the NCLA, 49% of patients are still presenting with advanced and incurable disease with the associated impact on prognosis, although this is down from 53% in 2016. This confirms an urgent need to diagnose lung cancer earlier when curative treatment is possible.
CRUK estimates that up to 79% of lung cancer cases in the UK are preventable and that 72% of lung cancer cases in the UK are caused by smoking therefore smoking cessation will need to be an integral part of the drive to reduce the level of lung cancer diagnosis over time.
Alongside lung cancer, it is expected that the Targeted Lung Health Checks (TLHC) Programme will also identify other conditions, including undiagnosed COPD. COPD causes around 23,000 deaths in England each year, with one person dying from the condition every 20 minutes. Again, there is evidence that early diagnosis and treatment can significantly improve outcomes for patients.
At the start of the COVID 19 pandemic, referrals for suspected Lung Cancer declined significantly. Unlike most other cancers, some of which have recovered to above pre-pandemic levels, the number of two week wait referrals across West Yorkshire and Harrogate remains low at just over 60% of pre-pandemic levels (February 2021). Over the year to February 2012 around 11% fewer treatments have been carried out on Lung Cancer Patients and there is emerging evidence that patients have been presenting at a later stage when their cancer is no longer treatable. In his letter to the system in September 2020, Simon Stephens emphasised the importance of the TLHC projects in helping to redress the balance and find early stage treatable cancers.
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Background and context
The Targeted Lung Health Checks programme was announced in a press release on 8th February 2019 and is part of the NHS Long Term Plan (Jan 2019). The aim of the programme is to deliver Lung Health Checks to populations with the highest risk of developing lung cancer in order to identify lung cancer at an earlier stage. The national programme is supported by a National Protocol (https://www.england.nhs.uk/wp-content/uploads/2019/02/targeted-lung-health-checks-standard- protocol-v1.pdf) and Quality Standard (https://www.england.nhs.uk/wp- content/uploads/2019/02/targeted-screening-for-lung-cancer-quality-assurance-standard.pdf ), which detail a minimum framework for delivery.
Lung Health Checks will be offered to patients in the age cohort 55-74 by a letter or phone call from their GP. At the Lung Health Check, a nurse led service will assess the patients using two recognised lung health check assessment tools, which provide a 6-year risk score for lung cancer. Patients identified at a high risk will be offered a referral for a low dose CT (LDCT) scan, which will be delivered locally.
In the short term, due to COVID 19, Lung Health Checks will be carried out using a remote model either via the telephone or video link however there is an expectation that in the new financial year the service will revert to a face to face model, with the reintroduction of Spirometry to assess wider lung health. The Addendum which outlines the remote model can be accessed at the following https://www.england.nhs.uk/wp-content/uploads/2019/02/C0699-tlhc-pathway-addendum.pdf
The TLHC pathway includes repeat scans conducted on indeterminate findings and a scan at 24 months where the initial scan was negative. See Figure1 – High Level Patient Pathway (National Protocol 2019 and Quality Assurance Standard 2020) below;
Figure 1 High level patient pathway
Evidence from areas where this service model has been piloted has demonstrated that around 65% of patients identified with lung cancer are diagnosed at stage I. This contrasts with only 18% of
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patients diagnosed at stage I when referred by their GP (NHS Long Term Plan, 2019). There is also good international evidence emerging about the long-term impact of similar programmes on longer term survival.
Case for Change
In 2018, three GP practices in Bradford joined a pilot Tackling Lung Cancer Programme developed and funded by the West Yorkshire & Harrogate Cancer Alliance (WY&HCA).
The service started on 29th July 2019 and by the end of January 2020, 1593 patients had received a Lung Health Check, 591 patients had received a LDCT scan and had been informed of the outcome. 24 patients were upgraded on to the lung cancer pathway for further investigations and 10 patients had been diagnosed with lung cancer and had an agreed treatment plan in place. In terms of yield 1 lung cancer was found for every 59 Low Dose CT scans. The pilot demonstrated a clear stage shift towards earlier diagnosis. Stage I/II diagnoses increased from 26% in 2016 to 50% for patients diagnosed after a Lung Health Check.
As the pilot was underway Bradford was initially excluded from the NHS England programme, however in 2020, Bradford and Craven CCG was offered funding as part of an expansion. This followed the success of the Bradford pilot combined with high levels of deprivation, smoking and lung cancer mortality.
Funding has been offered based on a population of 50 000 patients in the 55 - 74 age range, which is just under 50% of the total eligible population. Based on available CCG data 48% of this age cohort will be ever smokers. Approximately 24 000 patients will be invited to a Lung health Check of which is it is expected that around 11 000 will go on to have a Lung Health Check, with 6000 of these (56%) identified as high risk and offered a Low Dose CT scan. The model predicts that approximately 260 lung cancers could be identified during the course of the project. 75% of these are expected to have an early diagnosis of grade I/II and be eligible for curative treatment. (See National Modelling tool in Appendix A)
The smoking rates across Bradford and Craven GP Practices is currently on average 21.9%, but this varies significantly between practices from around 7% to over 45%. This compares to the national average of 14.1%. Smoking cessation support will be offered to all smokers attending Lung Health Check appointments and help reduce the rates further.
Delivery Model
The evaluation of the TLHC project has been designed to review different models of delivery. During the Bradford pilot project it was agreed by stakeholders that the preferred approach for the population would be the delivery of Lung Health Checks in primary care, with onward referral for patients assessed to be at risk of lung cancer to a mobile LDCT based in the local area. This would be procured and supported by Bradford Teaching Hospitals, who would provide the Radiology and Respiratory elements of the service
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The Bradford and Craven steering group for the original pilot has been reconvened to support the roll out of the national project, with membership from across Bradford and Craven CCG, Primary Care including the LMC, Local Government, Bradford Teaching Hospitals and the West Yorkshire and Harrogate Cancer Alliance, which has responsibility for oversight of the project.
At the initial Steering Group meeting the outcomes of the pilot were reviewed and, based on the evaluation, the Steering Group proposed a continuation of the split model of delivery (see draft Patient Pathway Appendix B). In terms of the Primary Care delivery of the Lung Health Checks, it was agreed that, although working at individual practice level had been successful for the three areas in the pilot, this would not offer a sustainable model for wide roll out across multiple Bradford and Craven Practices and a single LHC provider should be identified.
The Steering Group has also looked at the most appropriate identify a target population of 50 000 patients from a total of around 120 000 in the age cohort. A number of methods were presented to the Steering group, including splitting the population by deprivation and smoking at both Practice and PCN level. It was agreed that, due to the clear link between smoking and lung cancer that practice populations would be prioritised with the highest levels of smoking. The proposed list of practices is included in Appendix C.
Contracting and Financial Planning – proposed next steps
Funding
The national programme, which is overseen locally by the West Yorkshire and Harrogate Cancer Alliance, has allocated of £5,530,196 over the life of the for the development and delivery of a Targeted Lung Health Check programme for Bradford and Craven CCG. Due to the impact of COVID on the progression of the project, it will be challenging to deliver to the whole population including 24 month follow up scans by the March 24 deadline, which is the end of the NHS funding round, however the NHSE team have given assurance that the whole project amount will be made available. There is also a strong expectation that the programme will expand beyond that timeframe into a full national roll out.
The estimated financial breakdown to each aspect of the project is shown in Appendix D.
Radiology and Respiratory Support
In terms of the Radiology and Respiratory elements of the service, including the procurement and oversight of the mobile LDCT, it is proposed that this work would be carried out by Bradford Teaching Hospitals NHS Trust (BTHFT) under a direct award/ contract variation. BTHFT would be the natural Trust for most of the patients in the proposed cohort and there is an expectation that patients will where possible, be supported by their local trust through the process.
BTHFT have confirmed that they are able to support the programme and have completed a business case to ensure that they are resourced to effectively manage the patients without significant impact on existing services. They also have experience of the successful delivery of the Bradford pilot project and have infrastructure in place to manage the LDCT element of the service.
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This acute element of the service would be valued at approximately £3,600,000 across the duration of the project, including the procurement of the mobile LDCT.
Lung Health Checks – Primary Care Service
In terms of the LHC element of the service, it is proposed that a single provider is identified to deliver the LHC service to all patients within the identified cohort. Although there are a limited number of organisations with experience of TLHC delivery and there is strong interest from key individuals involved with the pilot, it is recognised that there are a number of organisations within Bradford and Craven and the wider West Yorkshire footprint who may be interested in offering the service, including a number of GP federations. It is therefore proposed that, in order to ensure that the process protects the CCG against legal challenge, for this element of the service a Prior Information Notice (PIN) is issued to test the market. The next steps will then be dependent on the outcome of the PIN. North of England CSU have been approached to provide procurement support for the project and the costs are factored into the overall budget costs.
This element of the service would be valued at approximately £880,000 across the duration of the Lung Health Check element of the project which is estimated to run until March 2023
Benefits Summary
The key aim of this project is to improve the outcomes for patients who are diagnosed with Lung Cancer across Bradford and Craven. As outlined above, if the project is in line with modelling expectations from the national programme, 260 patients will be diagnosed with Cancer and of these lives will be saved as a result of earlier diagnoses. The delivery of Lung Health Checks should result a stage shift from 25% of patients being diagnosed at an early stage to 75% with a corresponding reduction of patients being diagnosed at a later stage III/IV, when curative treatments are less likely to be possible.
Raising public awareness of the symptoms of cancer it is also the ambition of the West Yorkshire & Harrogate Cancer Alliance with the aim of reducing the number of lung cancer presenting as an emergency admission.
Primary prevention through reducing the numbers of people who smoke remain important and an the project will work closely with the local smoking service to promote smoking cessation within the target group. Any smokers attending a Lung Health Check will be offered very brief advice and the opportunity to quit, at what might be a teachable moment.
In addition to lung cancer, when delivery reverts to a face to face format, the Lung Health Checks will also help to identify other respiratory conditions at an earlier stage. This would include COPD, Bronchiectasis, Emphysema and Asthma. Resulting in more effective management of the condition for the patient and improved outcomes.
The Low Dose CT scan could also result in other incidental findings including renal conditions, and cardiovascular conditions.
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The project will also provide benefits to the Primary Care workforce by increasing skills in spirometry and offering access to wider national and local training offers, including IRMER training, Good Clinical Practice and Communicating with High Risk individuals. National training is also available to Radiologists working on the project including British Society of Thoracic Imaging (BSTI) Lung Nodule Workshop.
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References
NHS England - Targeted Screening for Lung Cancer with Low Radiation Dose Computed Tomography - Standard Protocol prepared for the Targeted Lung Health Checks Programme, (2019) https://www.england.nhs.uk/wp-content/uploads/2019/02/targeted-lung-health-checks-standard- protocol-v1.pdf
Targeted Screening for Lung Cancer with Low Radiation Dose Computed Tomography Quality Assurance Standards prepared for the Targeted Lung Health Checks Programme https://www.england.nhs.uk/wp-content/uploads/2019/02/targeted-screening-for-lung-cancer- quality-assurance-standard.pdf
Technical guide for TLHC participant management during the coronavirus pandemic Addendum to participant pathway Targeted Lung Health Checks programme https://www.england.nhs.uk/wp- content/uploads/2019/02/C0699-tlhc-pathway-addendum.pdf
Crosbie, PA et al (2018) Second round results from the Manchester ‘Lung Health Check’ community- based targeted lung cancer screening pilot, Thorax, 2018;0:1–5.
CRUK, Lung Cancer Statistics, https://www.cancerresearchuk.org/health-professional/cancer- statistics/statistics-by-cancer-type/lung- cancer#:~:text=There%20are%20around%2047%2C800%20new,23%2C100%20new%20cases%20in% 202017.
NELSON (2018) ISALC 19th World Conference on Lung Cancer, NELSON Study Shows CT Screening for Nodule Volume Management Reduces Lung Cancer Mortality by 26 Percent in Men, https://wclc2018.iaslc.org/media/2018%20WCLC%20Press%20Program%20Press%20Release%20De %20Koning%209.25%20FINAL%20.pdf
Horeweg, N. et al (2014), Detection of lung cancer through low-dose CT screening (NELSON): a prespecified analysis of screening test performance and interval cancers, The Lancet, vol 15, issue 12, page 1342-1350
NHS England - NHS Long Term Plan (Jan 2019) https://www.longtermplan.nhs.uk/
Royal College of Physicians, Annual Report 2020 (2018 cohort) National Lung Cancer Audit (NLCA) https://www.rcplondon.ac.uk/projects/outputs/annual-report-version-2-published-march-2021
Public Health England, Public Health Profiles 2019 https://fingertips.phe.org.uk/
Yuan,P et al (2016) Time to Progression of NSCLC FROM Early TO Advanced Stages: An analysis of data from SEER Registry and a Single Institute, Scientific Reports, Nature https://www.nature.com/articles/srep28477
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Appendix
Appendix A – National Modelling Tool Applied to Bradford and Craven Population
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Appendix B – Draft Patient Pathway
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Appendix C – Practice Selection by Smoking Rates
Affinity Care B83009 Sunnybank 28.9 2557 434 17.0% Five Lane Ends B83064 Haigh Hall 30.1 2176 375 17.2% PCN 4 B83604 Lister Surgery 48.6 328 57 17.4% Five Lane Ends B83056 Moorside 31.6 1732 314 18.1% PCN 6 B83621 Parkside 44.4 474 86 18.1% Affinity Care B83030 Thornton & Denholme 24.1 2234 408 18.3% LINGHOUSE MEDICAL WACA B83008 CENTRE 37.7 2128 392 18.4% PCN 5 B83026 Primrose 52.1 497 93 18.7% PCN 5 B83661 Moor Park 47.3 330 62 18.8% Affinity Care B83054 Haigh Hall 33.0 1338 252 18.8% Little Horton Lane - PCN 6 B83653 Gilkar 49.3 862 164 19.0% Affinity Care B83049 Cowgill 30.1 1070 205 19.2% PCN 5 B83626 Valley View 49.0 616 119 19.3% Bradford North West B83641 Ashwell 50.0 763 148 19.4% Affinity Care B83063 Shipley & Westcliffe 28.5 4097 809 19.7% PCN 4 B83614 Picton 49.5 857 172 20.1% Modality B83033 KILMENY SURGERY 31.9 2931 589 20.1% PCN 6 B83628 Clarendon 49.8 772 157 20.3% FARFIELD GROUP Modality B83021 PRACTICE 34.7 2927 596 20.4% PCN 4 B83660 Bilton 51.5 597 122 20.4% Modality B83023 HOLYCROFT SURGERY 35.3 2126 440 20.7% Hollyns Health & Bradford North West B83045 Wellbeing Centre 39.3 3025 651 21.5% PCN 5 B83032 Bradford Moor 48.9 545 118 21.7% Dr Hamdani PCN 5 Y01118 (Eccleshill?) 33.4 686 149 21.7% PCN 5 B83629 Peel Park 43.7 476 104 21.8% PCN 6 B83627 Frizinghall 36.2 524 117 22.3% Five Lane Ends B83062 Ashcroft 40.4 1592 359 22.6% Bradford North West B83012 Manor 39.8 1631 371 22.7% Five Lane Ends B83016 Farrow 45.9 1028 245 23.8% PCN 4 B83052 Kensington Partnership 46.9 2809 686 24.4% Dr Akbar (Hillside PCN 5 B83611 Bridge) 48.8 691 170 24.6% PCN 5 B83058 Avicenna 50.2 545 135 24.8% PCN 7 B83010 Parklands 42.0 2090 522 25.0% PCN 5 B83005 Thornbury 49.2 925 236 25.5% PCN 7 B83035 Horton Park 49.6 1337 359 26.9% PCN 6 B83622 Kensington Street 46.6 575 158 27.5% BD4+ B83015 Tong 49.5 1677 511 30.5% PCN 5 B83657 Bevan 51.2 310 146 47.1% 51878 21.9%
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Appendix D – High Level Financial Model
Financial Modelling - Bradford and Craven Lung Health Check project
Available Budget Total Fixed Allocation (£327,778 per year) £1,311,112 Variable allocation Based on £264 per scan expected £4,219,084 Total Budget allocation £5,530,196
Core Progamme Management Cost Total Allocation
Including: WY&H Cancer Alliance Programme Management and Bradford and Craven CCG Management Support Total Programme Management Cost £310,000 Lung Health Check Costs Total Allocation Lung health Check Patient Numbers: Patients in Cohort 25300 Patients Booking LHC 12650 Set Up costs (including IT, infratstructure and training) £50,000 Budget for Lung Health Check Delivery £830,000 Total Budget for Lung Health Check £880,000 CT Scanning Costs (Using 56% National Modelling conversion from LHC to LDCT) CT Scanning numbers across the project Patients with Initial CT 5959 Patients with 24 month follow up CT 4923 Patients 3 month Nodule follow up 846 Patients 12 month Nodule follow up 846 Total number of scans over 4 years 12574 Approximate cost per scan (Mobile LDCT £80 per scan) £1,000,000 Underutilisation @50% £500,000 Total Mobile Scanning Cost (approx) £1,500,000 Secondary Care Costs (Radiology and Respiratory service) Estimated cost £2,100,000 Communication and Engagment Including media and publications - Estimated cost £100,000 Total cost of programme £4,890,000
Over/Underspend £640,196
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Agenda item 10
Name of meeting Governing Body Meeting date 13 July 2021
Risk Register Report: Cycle 1 Catherine Smith, Title of report Report author(s) Corporate Governance 2021-22 (May – June) Manager Catherine Smith, Lead(s) / SRO Helen Hirst, Chief Officer Report lead(s) Corporate Governance Manager
Paper summary and/or key discussion points
The purpose of the paper is to provide the Governing Body with details of ‘high level risks’ (those scoring 15 or more), new risks identified and risks closed during the current risk review cycle.
Corporate risk register (updated bi-monthly)
There have been four new risks added to the risk register during this cycle: o Risk 1858 relating to the CCG failing to adequately discharge its responsibilities with regard to its own dis-establishment on 31 March 2022 which has a risk score of 16 and is rated as a ‘serious’ risk. o Risk 1862 relating to the financial arrangements for H1 2021/22 which have been confirmed and a budget approved by the Governing Body that includes a £7m savings target for the first six months of the year and additional funding from the Elective Recovery Fund (ERF) to pay for independent sector acute elective activity. ERF performance is assessed at the West Yorkshire ICS level and therefore our funding depends on the performance of all organisations across West Yorkshire. There is a risk that the CCG will not achieve its H1 break-even target if these savings cannot be identified and if Elective Recovery Fund income is not received to match additional activity costs. This risk has a score of 16 and is rated as a ‘serious’ risk. o Risk 1857 relating to staff wellbeing, morale and motivation due to the impact of planned legislation to transfer commissioning functions, people, assets and liabilities to integrated care systems which has a risk score of 12 and is rated as a ‘high’ risk. o Risk 1861 relating to a recent direction from national policy and decision to change BCG vaccine delivery from birth to four weeks with neonates which has a risk score of 9 and is rated as a ‘high’ risk. There are three risks at the ‘critical’ level (scoring 20 or 25). Risk 1613 relates to the demand for mental health services, risk 1495 relates to the impact of the Covid-19 pandemic and risk 1582 relates to increased health inequalities due to socio-economic and ethnicity factors. There are 17 risks classed as ‘serious’ (scoring 15 or 16). No risks have increased in score this cycle. Seven risks have decreased this cycle, as detailed in the paper. Of these, one risk has reduced from a ‘critical’ (with a risk score of 20) to a ‘serious’ risk (with a risk score of 16) – this relates to the impact of Covid-19 on care homes (risk 943). Three risks which were rated as ‘serious’ risks in the last cycle have reduced in score – end of life experience (risk 1574) previously scored 16 has reduced to 12 (a ‘high’ risk); health outcomes for children looked after (risk 1134) previously scored 16 and has reduced to 12 (a ‘high’ risk); and impact of backlog on continuing healthcare referrals (risk 1579) previously scored 16 and the score has now reduced to 1 (a ‘low’ risk). Three risks have been marked for closure during the cycle. These are risk 1587 relating to staff wellbeing and morale due to the pandemic (which has been superseded by risk 1858), risk 1370 relating to local care direct capacity and risk 1693 relating to the financial position for 2020/21 (M1 to M12) which
Page 1 of 2 153 154 have been closed as they are both no longer relevant to the CCG.
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
A robust risk management framework is essential to supporting the delivery of the CCG strategy. The CCG’s new assurance framework is in the early stages of development. This will set out the higher- level and longer-term risks to achievement of the CCG strategy. The assurance framework is underpinned by the corporate and Covid-19 risk registers which set out the CCG’s more operational risks and their management. See the Covid-19 and corporate risk logs.
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
The governing body is asked to receive and note the risk report and high level risk log.
Appendices (or other supporting papers) Appendix 1: Risk report including scoring matrices Appendix 2: Risk overview diagram Appendix 3: Corporate risk register; high level risk log
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Risk Register Report: Cycle 1 2021-22 (May 2021 – June 2021)
1.0 Purpose of the Report
1.1 To provide the Governing Body with details as at the end of Risk Cycle 1 2021-22, of:
‘high level’ risks – those rated as ‘serious’ or ‘critical’ risks (scoring 15 or more) new risks added to the risk register during the current risk cycle risks that have increased or decreased during the cycle risks closed during the cycle.
2.0 Risk Review and Reporting Process
2.1 There are normally six risk review cycles per annum. The process for the review and reporting of the CCG’s corporate risk register is as follows:
Review of individual risks by risk Owners Review of individual risks by allocated Senior managers Review of all risks by the Senior Leadership Team (SLT) Review of all risks by either the Finance and Performance Committee (FPC) or Quality Committee (QC) Further report to SLT prior to Governing Body reporting by exception Reporting of risks scoring 15 or more, plus new and closed risks, to the Governing Body.
2.2 In addition, the corporate risk register is a standing item on the agenda of standard Audit and Governance committee meetings in order to provide assurance on the risk management process.
2.3 During this cycle work has continued to encourage risk owners and senior managers to review risk scores and narratives to ensure that the risks are updated in line with recommendations made by Internal Audit. A request was also made that risks were reviewed and updated to reflect that this is a transitional year for the CCG as we look towards the development of the ICP/ICS.
2.4 Following discussion at the Governing Body meeting in May two risks have been added to the risk register during this cycle to reflect the CCG transition to the ICP/ICS. Risk 1858 reflects that there is a risk that the CCG will fail to adequately discharge its responsibilities relating to its dis-establishment on 31st March 2022 resulting in a disorderly transfer and has a score of 16 classing it as a ‘serious’ risk. Risk 1857 refers to the risk to staff wellbeing, morale and motivation during the transition and is classed as a ‘high’ risk with a score of 12. Further detail can be found in section 3.3 of the report.
2.5 The risk register was presented to the Senior Leadership Team meeting on 26th May where discussion took place in relation to the scores for several risks including those relating to the dis- establishment of the CCG, compliance with liberty protection standards and the impact of the backlog 1
155 156of continuing healthcare referrals. Following the meeting, all risk owners and senior managers were contacted to request that any necessary updates were made. Following the meeting it was decided that the current score relating to the dis-establishment of the CCG would remain. Consideration was given as to whether the score for risk 1495 relating to the impact of the Covid-19 pandemic could be reduced, but it was felt to still be an accurate reflection of the current position. A request was made that when a risk reaches its target score rating, colour coding be used to highlight this. This is something that will be taken forward by the Corporate Governance Team.
2.6 The risk management process had been discussed at a meeting of the ALT on 18th May and the support of the ALT in undertaking thorough reviews of risk scores and narratives had been noted.
3.0 Corporate Risk Cycle 1 May - June 2021
3.1 Please see Appendix 2 for the CCG risk overview diagram.
3.2 Numbers of risks and average risk scores are shown in the table below:
Numbers of risks and average risk scores
Total number of open risks 49
Number of open risks aligned to Finance and Performance Committee (FPC) 19
Number of open risks aligned to Quality Committee (QC) 25
Number of open risks aligned to both Finance and Performance and Quality committee 5
CCG average risk score 12.14
FPC average risk score 10.89
QC average risk score 12.80
3.3 Four new risks were added to the risk register in the current risk cycle, details of which can be found in the table below.
Details of new risks
Risk scores are calculated by multiplying the impact by the likelihood.
Risk Risk summary Current risk score reference number 1858 There is a risk that the CCG fails to adequately discharge its responsibilities with regard to its own dis-establishment on 31 Overall score is 16 (Both FPC March 2022, due to unmanageable demand and/or and QC) insufficient capacity of CCG managers (working with ICS and Impact score is 4 ICP partners), resulting in a disorderly transfer of CCG functions, people, assets and/or liabilities to the West Likelihood score is 4 Yorkshire integrated care system (ICS) that is not in accordance with relevant guidance and timescales.
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156 1862 157 The financial arrangements for H1 2021/22 have been confirmed and a budget approved by the Governing Body that Overall score is 16 (FPC) includes a £7m savings target for the first six months of the year and additional funding from the Elective Recovery Fund Impact score is 4 (ERF) to pay for independent sector acute elective activity. ERF performance is assessed at the West Yorkshire ICS Likelihood score is 4 level and therefore our funding depends on the performance of all organisations across West Yorkshire. There is a risk that the CCG will not achieve its H1 break-even target if these savings cannot be identified and if Elective Recovery Fund income is not received to match additional activity costs. 1857 There is a risk to staff wellbeing, morale and motivation due to the impact of planned legislation to transfer commissioning Overall score is 12 (Both FPC functions, people, assets and liabilities to integrated care and QC) systems and delegation to integrated care partnerships Impact score is 4 involving an increase in workload for some staff, lack of clarity around new roles and objectives in addition to personal Likelihood score is 3 anxieties around change. 1861 There is a risk due to the recent direction from national policy and decision to change BCG vaccine delivery from birth to Overall score is 9 (QC) four weeks with neonates. The current risk rating is an estimate as a further assessment needs to be made. Impact score is 3
Likelihood score is 3
3.4 There are three risks currently classed as ‘critical’ (scoring 20 to 25) on the risk register, details of which can be found below:
Details of critical risks
Risk scores are calculated by multiplying the impact by the likelihood. Risk Risk summary Current risk score reference number 1613 Demand for mental health services - Risk that demand for mental health services outweighs Overall score is 25 (QC) capacity and / or require a different focus going forwards due to increased need arising from the pandemic, including the Impact score is 5 impact on key workers (for example PTSD). The impact is inability of local people to access appropriate mental support Likelihood score is 5 in a timely way which would reduce their health and wellbeing. 1495 COVID-19 pandemic - There is a risk that the COVID-19 pandemic will result in Overall score is 25 (QC) substantial fatal outcomes in high-risk groups and economic and societal disruption. The demand for health services may Impact score is 5 outstrip resources available. Likelihood score is 5 1582 Increased health inequalities due to socio-economic and ethnicity factors - Overall score is 20 (QC) There is a risk of increased health inequalities due to socio- economic and ethnicity factors during the pandemic Impact score is 5 (evidence to date is that the pandemic is impacting on deprived and BAME groups more than average). The impact Likelihood score is 4 is failure to meet statutory duties relating to reduction of health inequalities / disproportionate suffering for certain groups. 3
157 158 3.5 ‘Serious’ risks are those scoring 15 or 16. The current number of ‘serious’ risks is 17 in total. Risks 1858 and 1862 are new risks and have been reported in sections 3.3 in this report. Two risks will be reported in private and the remaining ‘serious’ risks are noted below:
Details of serious risks Risk scores are calculated by multiplying the impact by the likelihood.
Risk Risk summary Current risk Previous Cycle 1 update reference score risk score number 1694 Underlying financial position Overall score Risk has Financial arrangements risk - there is a risk that the is 16 been static in for H1 2021/22 identified, (FPC) CCG will take an underlying Impact is 4 score for but these do not mitigate financial deficit into 2021/22 Likelihood is three cycles. this risk. Roll-forward due to the inability to deliver 4 arrangements from H2 the original planned savings 2020/21 confirm an of £13.8m as a result of the underlying deficit of £4m disruption of activities carried forward to H1 caused by the pandemic. 2021/22. Arrangements for H2 not clarified, but are not expected to resolve the expected underlying deficit position. Now reviewing financial plans across Place organisations to identify recurrent savings opportunities. 1135 Adult Autism and/or ADHD Overall score Risk has No further update. Assessment and Diagnosis is 16 been static (QC) Impact is 4 for 12 cycles. Likelihood is 4 1094 Child autism and/or ADHD Overall score Risk has Paper presented to assessment and diagnosis is 16 been static in Governing Body in March (QC) Impact is 4 score for 21 2021 outlining the current Likelihood is cycles. position and planned next 4 steps. The presentation to MHLDA HCP was deferred due to the chairs decision to hold a neuro- diversity focused learning event. As a result of this discussion there are plans for a CYP focussed systems discussion to be led by Mark Mon-Williams and his team A multi- agency business case to address the system failure to meet the NICE standard of referral to first appointment within three months and to increase support for families prior to referral, during the
4
158 Risk 159 Risk summary Current risk Previous Cycle 1 update reference score risk score number assessment process and following receipt of outcome is in development. An update will be provided to the MHLDA HCP meeting in May. Meeting with systems COOs held 27 April to share latest data and gain support for business case development. Meeting to be held with Morecambe Bay CCG 6.5.21 to explore their tiered approach to assessments. 943 Covid impact on care Overall score Overall score As of May 2021 Infection homes is 16 was 30 rates have reduced, 4 (QC) Impact is 4 Impact was 4 homes in Bradford have a Likelihood is Likelihood reported outbreak within 4 was 5 the 0-28 day cycle and Craven has 1 home therefore risk rating reduced to 16 . However we are seeing increasing numbers of homes that require improvements with 7 homes currently rated as inadequate and placed in special measures and there is a need to understand enhanced support requirements and any outliers from a CQC perspective. There is a need to understand enhanced support requirements and any outliers from a CQC perspective as well as ongoing funding gaps to health and social care and the long term effects of COVID to the care sector in terms of acuity of needs and volume of demand. 940 BTHFT maternity services Overall score Risk has Monthly CCG internal is 16 been static in meeting in place to (QC) Impact is 4 score for 6 triangulate information Likelihood is cycles. between Better Births and 4 Quality outcomes.
1739 Risk of burnout amongst the Overall score Risk has Seeking further assurance NHS workforce as the is 15 been static in from workforce colleagues (QC) system continues to Impact is 5 score for 1 regarding any gaps. manage the significant 5
159 Risk 160 Risk summary Current risk Previous Cycle 1 update reference score risk score number acute and now longer-term Likelihood is cycle. demands of COVID-19 in 3 addition to dealing with the backlog of elective care 1735 PC/VDI desktop resources Overall score Risk has In mid-February the CCG regarding a new release of is 15 been static in was made aware that a (both FPC functionality in SystmOne Impact is 5 score for 1 new release of and QC) Likelihood is cycle. functionality in SystmOne 3 was imminent. The release was to include the record of all COVID Tests done (both positive and negative results) and this functionality would consume a significant amount computing power, mainly memory (RAM) resources. There is a risk that following release of this functionality overall IT system performance would deteriorate. 1726 There is a risk that unpaid Overall score Risk has SystmOne template carers are not identified as is 15 been static in available to primary care (QC) carers and supported. Impact is 5 score for 1 staff including prompts to Likelihood is cycle. follow up health needs 3 and identify Safeguarding concerns. Local strategy includes priority to identify unpaid carers on SystmOne record GP Safeguarding lead and Specialist Health Practitioner - Safeguarding Adults to address needs of carers with GPs during 2021 including focused bulletin March 2021 Planned engagement with PCNs, especially those with low rate of carers identified, to increase practice use of template, identify unpaid carers and identify and meet healthcare support needs 1713 Covid-19 vaccinations - Overall score Risk has The risk remains the there is a risk that a large is 15 been static in same as although we are (both FPC proportion of our population Impact is 3 score for 3 seeing increasing and QC) will not receive the Covid-19 Likelihood is cycles. numbers vaccinated, the vaccination due to a variety 5 hesitancy remains within of reasons including: specific groups. We have vaccine availability; low uptake in the three workforce to deliver; central PCNs compared to
6
160 Risk 161 Risk summary Current risk Previous Cycle 1 update reference score risk score number individual beliefs and other PCNs sharing of misinformation. 1594 Care Home Financial Overall score Risk has The risk remains as Sustainability - there is a is 15 been static in described in previous (FPC) risk to the financial Impact is 5 score for 12 reports. sustainability of the care Likelihood is cycles. home market due to the 3 costs and issues arising from the pandemic. The impact is reduction in care home capacity / pressure on other parts of the health and care system. 1404 0-19 Services impact on Overall score Risk has BDCFT have reported CCG commissioned is 15 been static in significant and increasing (QC) services Impact is 3 score for 10 challenge within the Likelihood is cycles. school nursing service. 5 They plan to mitigate immediate risks by transforming service delivery from the current locality-based model to a corporate model utilising a skill mix approach. The CCG will continue to work with public health and BDCFT to minimise the impact on service provision for children and young people and primary care. 1098 Performance against Overall score Risk has Impact of Covid-19 has constitutional standards is 15 been static in reduced however now (FPC) Impact is 3 score for 7 significant backlog of Likelihood is cycles. people waiting for 5 treatment. Draft recovery plans have been submitted to NHSE. Income linked to delivery through Elective Recovery Fund (ERF). Emphasis will now move to managing against recovery trajectories submitted as part of the H1, 2021/22 plan. 964 Vulnerability to cyber attack Overall score Risk has Risk not reviewed during is 15 been static in this cycle. (FPC) Impact is 3 score for 7 Likelihood is cycles 5
3.6 No risks have increased in score during the current risk cycle.
7
161 1623.7 Seven risks have decreased in score during the current risk cycle. Risk 943 can be found in section 3.5 (this risk reduced from a score of 20 to 16). Details of the remaining risks can be found below.
Risk Risk summary Previous Current Cycle 1 update reference score risk score number 1574 End of life experience 16 Overall Risk reduced as BTHFT offers video score is 12 calls to families, has introduced a single (QC) Impact is 3 point of contact and allows a relative to visit a patient who is at the end stage of Likelihood life. is 4 1134 Health outcomes for 16 Overall Risk downgraded to 12 to reflect the children looked after score is 12 work that has been undertaken to date. (QC) Impact is 3 The new clinical model has been implemented and GPs recruited. Likelihood Following a successful waiting list event is 4 the revised trajectory shows that the backlog of long waits will be cleared by Dec 2021 with an expectation that the numbers of CLA waiting for an IHA will be within normal limits (when compared with other areas) by June. We will continue to monitor progress with a view to downgrading the risk level of 12 further. 1326 Sustainability and 12 Overall Risk has been reduced as there has productivity of Bradford score is 9 been an increased focus on ensuring (QC) Community Partnerships Impact is 3 the sustainability of CPs - with additional people being assigned to Likelihood take this work forward as it is seen as is 3 being critical to the ICP development locally. 1036 Quality of stroke care 9 Overall Risk has decreased to 8 due to score is 8 improved governance via Healthy (QC) Impact is 4 Hearts Board oversight. However some variances in outcomes persist due to Likelihood workforce challenges causing delays in is 2 the pathway, therefore the risk will to be monitored risk until normal limits are maintained for one cycle and the new governance for place and ICS is agreed.
8
162 Risk 163 Risk summary Previous Current Cycle 1 update reference score risk score number 1575 Complaints/legal 9 Overall The NHSE CHC assurance tool (CHAT) challenge due to score is 2 has been completed and we are RAG (FPC) suspending means- Impact is 1 rated green within our CHC Framework testing during Covid-19, process. Reporting within the NHSE Likelihood Sitrep report for C19 is demonstrating is 2 activity above the projected trajectory. Discussion regarding the weekly activity reports at the CHC Strategic Group ensures explanations regarding delays or difficulties within the system are understood and assistance is swift once an issue has been raised.
This risk was increased due to inactivity within the backlog of current referrals which PCD were unable to complete due to the C19 Backlog cases. This risk has been reduced given we are commencing work on this caseload and no complaints have been received in relation to delays. All complaints are monitored and managed by the Patient experience team. 1579 Impact of backlog on 16 Overall The C-19 CHC Backlog has now been CHC referrals score is 1 completed and whilst there is a waiting (QC) Impact is 1 list for new cases referred in whilst the backlog work was being completed, this Likelihood is reducing on a weekly basis. The risk is 1 scores in relation to this have therefore been reduced. The risk remains until we have completed the current backlog. Activity in relation to the new referral backlog continues to monitored on a weekly basis by the PCD management team and two weekly at the CHC Joint Oversight Group.
3.8 Three risks have been marked for closure during the current review cycle and these are detailed below: Details of closed risks Risk scores are calculated by multiplying the impact by the likelihood.
Risk Risk summary Current risk Cycle 1 update reference score number 1587 Risk to staff wellbeing and Overall score Risk marked for closure as this has been morale due to the pandemic is 12 superseded by risk 1858 which relates to (FPC) Impact is 3 staff wellbeing and morale due to the Likelihood is impact of planned legislation to transfer 4 commissioning functions to integrated care systems (scoring 12).
9
163 Risk 164 Risk summary Current risk Cycle 1 update reference score number 1370 Risk relating to local care Overall score Risk has been marked for closure as it is direct capacity is 12 no longer relevant to the CCG. (QC) Impact is 3 Likelihood is 4 1693 Financial position risk 2020/21 Overall score Risk has been marked for closure as it is (M7 to M12) - there is a risk that is 8 no longer relevant to the CCG. (FPC) the CCG will not achieve its in- Impact is 4 year break-even target for the Likelihood is period October to March 2021 2 due principally to a reduction in the CCG's resource baseline compared to the first 6 months of the year.
4.0 Recommendations
The Governing Body is asked to receive and note the high level risk report and risk log. Appendices
Appendix 1: Risk Scoring Matrices (from the Integrated Risk Management Framework) Appendix 2: Risk Overview Diagram Appendix 3: High Level Risk Log
10
164 165
Appendix 1: Risk Scoring Matrices and Risk Grading
Impact 3 Insignificant 4 Minor 5 Moderate 6 Major 7 Catastrophic Impact
Financial £1k - £10k Up to £50k Up to £250k Up to £1M Over £1M
Some minor injuries/ Many minor injuries/ Minor bruises/ Some major injuries/ ill- Multiple Harm discomfort/ ill-health - minor. ill-health – temporarily health - permanently injuries/infections incapacitating. affects wellbeing. incapacitating Unexpected Death <3 days absence RIDDOR reportable.
No significant effect on Noticeable effect on Significant effect on Patient care Clinical care Patient care impossible quality of care provided quality of care provided quality of care provided significantly impaired
Negligible negative Minor negative impact Moderate negative Major negative impact Catastrophic negative impact on access, on access, experience impact on access, on access, experience impact on access, experience and /or and /or outcomes for experience and /or and /or outcomes for experience and /or outcomes for people people with this outcomes for people people with this outcomes for people with this protected protected with this protected protected with this protected characteristic. characteristic. Minor characteristic. characteristic. Major characteristic. Negligible increase in increase in health Moderate increase in increase in health Catastrophic increase in health inequalities by inequalities by health inequalities by inequalities by health inequalities by widening the gap in widening the gap in widening the gap in widening the gap in widening the gap in Quality access, experience and access, experience access, experience and access, experience and access, experience and /or outcomes between and /or outcomes /or outcomes between /or outcomes between /or outcomes between people with this between people with people with this people with this people with this protected characteristic this protected protected characteristic protected characteristic protected characteristic and the general characteristic and the and the general and the general and the general population. general population. population. Potential to population. population. Potential to result in result in moderate Potential to lead to Potential to result in minimal injury requiring Potential to result in injury requiring major injury leading to incident leading to no/minimal intervention minor injury or illness, professional long-term death, multiple or treatment, peripheral requiring minor intervention. incapacity/disability permanent injuries or
11
165 166
3 Insignificant 4 Minor 5 Moderate 6 Major 7 Catastrophic Impact element of treatment intervention and overall irreversible health suboptimal and/or treatment suboptimal" effects, an event which informal impacts on a large complaint/inquiry number of patients, totally unacceptable level or effectiveness of treatment, gross failure of experience and does not meet required standards
National Performance National Performance Internal Standards not Repeated failure to Performance not achievable not achievable achievable meet internal standards (Intermittent) (Continuous)
Audit non- Breach of procedure/ Government Enforcing action conformance/advice Directive from Improvement Notice. Prohibition Notice. Investigation. from enforcers. enforcers.
Likelihood
Level Descriptor Description
1 Rare The event may occur only in exceptional circumstances
2 Unlikely The event could occur at some time
3 Possible The event should occur at some time.
4 Likely The event will probably occur in most circumstances.
5 Almost Certain The event is expected to occur.
12
166 167 Score and risk level
Score Risk Level
1-3 Low risk
4-6 Moderate risk
8-12 High risk
15-16 Serious risk
20-25 Critical risk
13
167 168
Appendix 2: Risk Overview Diagram
14
168 1495 1613 Risk ID Cor rae Risk Type Date Created 30/00QC 03/03/2020 QC 19/06/2020 169
Risk Our Population Our Population Category
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NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 11
Name of meeting Governing Body Meeting date 13 July 2021
Title of report Commissioning Assurance Report author Sue Baxter, strategic head Framework (strategic risks) of assurance Liz Allen, strategic director of Lead / SRO Report lead Sue Baxter organisation effectiveness
Paper summary and/or key discussion points Introduction The commissioning assurance framework (CAF) focusses on the most strategic and long-term risks to the delivery of the CCGs’ strategic objectives and as such is strongly aligned to our Commissioning Strategy (2020). The commissioning assurance framework was received by the Governing Body on the 9 March 2021 when it was agreed to receive it on a bi-meeting basis, including at today’s meeting the 13 July 2021 and future Governing Body meetings in 9 November 2021 and 8 March 2022.
Background
A brief description of the purpose of the CCG’s commissioning assurance framework.
An assurance framework is a comprehensive method for the effective and focused management of principal risks to meeting strategic priorities. It is a high level view of risk which sits above a corporate risk register and deals with strategic and long term risks. In simple terms, the CCG’s commissioning assurance framework sets out our strategic objectives and the risks to achieving these.
Risk grading
A risk can be defined as “an uncertain event or series of events that, should it occur, would have an effect on the achievement of objectives” and is measured in terms of impact and likelihood. Risk scores (both current and target) are calculated by multiplying the potential impact or severity of impact by the potential likelihood or frequency level to provide a risk score using a 5 x 5 matrix scoring system which produces a range of scores from 1 to 25. [Likelihood x impact = risk score]. The risk score determines the prioritisation and allocation of resource. Higher scores have a higher priority for action, as the impact of failing to reduce the risk is greater, the risk score are assigned grades as follows:
Table 1: grade of risk Score Risk level / grade
1-3 Low
4-6 Moderate
8-12 High
15-16 Serious
20-25 Critical
175 Page 1 of 3 176 Key controls Relate to management actions such as systems, processes, mechanisms already be in place and gaps in control are where there are plans in place to a specified timeframe but are not yet in-place.
Assurance relates to what mechanisms are in place to provide evidence of management actions and can include but are not limited to - key performance indicators, oversight groups / committees or other reporting assurance mechanisms such as internal audit reports or reviews by regulatory bodies, etc. Gaps in assurance can occur when no mechanism in place to report on progress or performance is below target
For any gaps in control or gaps in assurance associated actions are set out within the CAF with timeframes to redress the associated gap. Triangulation with the corporate risk register is provided whereby any related corporate risk and its current score is provided and finally a progress update summary of key changes is provided for each strategic risk.
How we use the CAF As well as providing an important tool of assurance for the Governing Body, the commissioning assurance framework is also reviewed by our senior leadership team and the associate leadership team. From cycle two the CAF will also be taken to the associate clinical directors. With the aim of broadening out the use of this framework to facilitate and engage our leaders and decision makers in the strategic risk management process.
The commissioning assurance framework update (June 2021)
The commissioning assurance framework is set out within Appendix 1 and has two tables, the first provides a summary and the second table provides the detail for each of our strategic risks.
Summary update (risks with increased scores)
o 1.1 failure to improve population health outcomes and to reduce health inequalities - this risk score has increased due to the COVID19 which has created significant waiting lists for services in acute and mental health. The long-term impact on the wider determinants of COVID19 is still not yet fully understood be we are already seeing increased demand on all sectors o 2.1 building strong relationships between Local Authorities and Health - there is a risk due to growing financial pressures created by an increase in demand for services that could result in strategic and operational plans not being realised. In addition, following on from COVID19 the impact on finances remains challenging during our recovery and o 3.2 failure to close the care and quality gap - the impact of COVID19 including the impact on long term conditions, delays in the identification of conditions such as cancer through lack of early presentation. Rise in frailty due to long term isolation and increases in mental health issues. Waiting times for diagnostics and planned care activity have increased over the period of the pandemic
The table below provides a summary of the strategic risks and their current scores.
Table 2: Commissioning assurance framework strategic risk summary
Risk Strategic Risk rating 1.1 There is a risk of failure to improve population health outcomes and to reduce health inequalities due to COVID19. Poor outcomes and health inequalities have been highlighted by the COVID19 pandemic with both direct and indirect impacts of COVID19 on the 16 economy, education as well as the physical health and mental wellbeing of our population particularly those living in the areas of worst socioeconomic deprivation 2.1 There is a risk due to the growing financial pressures created by an increase in demand for services could result in agreed strategic and operational plans to deliver improved health 16 and care not being realised 176 Page 2 of 3 177 3.1 There is a risk that unwarranted variations in quality and care cannot be effectively addressed due to shortfalls in workforce capacity, capability and skills resulting in failure to 16 ↔ close the care and quality gap (across BdC) 3.2 There is a risk that our efforts may not have the impact we desire due to some determinants of quality and outcomes which lie outside of the control of health and social 16 care resulting in a failure to close the care and quality gap (Quality improvement / assurance) 4.1 There is a risk that the changes to health services models required to achieve clinical and financial sustainability are not acceptable to key stakeholders, e.g. patients, the public 9 ↔ or elected representatives, and cannot be implemented. This would result in the failure of the act as one approach. 5.1 ICP establishment: There is a risk that we fail to gain sufficient organisational traction towards Integrated Care Partnership for Bradford district and Craven place, due to a range of factors. This includes: leadership challenges, failure to agree governance arrangements 12 ↔ and future form and function, resulting in failure to achieve a viable form in time to receive delegated responsibilities from the Integrated Care System 6.1 ICS people transition: there is a risk of CCG staff struggling to adapt to new, externally facing, system-focussed roles as we move towards the new Integrated Care System and Partnership operating models by 1 April 2022 due to the need for organisational form 12 ↔ change and individual CCG staff role flexibility and the normal factors associated with change, resulting in failure to successfully transition CCG staff. 7.1 There is a risk that we do not address the underlying financial deficit and establish a 16 ↔ financially sustainable position over the medium term as we exit the pandemic
Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
Our leadership: to provide assurance regarding delivery of our commissioning strategy including our strategic ambitions and specific outcomes. Each of our ambitions has at least one associated strategic objective and strategic risk, as follows: o Our population - 1.1 and 2.1 o Our partnerships - 3.1, 3.2, 4.1 and 5.1 o Our people - 6.1 o Our leadership - 7.1
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
The Governing Body is asked to: review and approve the CAF / strategic risk, as a fair and accurate reflection of the CCGs’ current strategic risk position and note the increases in risk scores for 1.1, 2.1 & 3.2
Appendices (or other supporting papers)
1. Commissioning assurance framework (at June 2021)
177 Page 3 of 3 178 Appendix 1
Our vision: by 2023 every person living in Bradford district and Craven will have the opportunity to spend more time enjoying life in the best of health
Commissioning assurance framework
Introduction Brought forward from the three predecessor CCGs’ governing body assurance framework the NHS Bradford District and Craven CCG commissioning assurance framework (CAF) identifies the principal risks to the delivery of the CCG’s strategic objectives and links to how we operate within the new CCG Commissioning Strategy. It sets out the controls that are in place to manage the risks and provides the assurances that show the extent to which the controls are having the desired impact. It identifies the gaps in control and therefore the key mitigating actions required to reduce the risks towards the target risk score. It also identifies any gaps in assurance and what actions can be taken to increase assurance to the CCG.
Summary overview The table below sets out the strategic objectives, the strategic risks that relate to them and highlights where gaps in control or assurance have been identified. Further details can be found on the supporting pages for each of the Strategic Risks.
Risk Risk Target Are there Are there
Strategic Objective Risk Strategic Risk Summary Current or GAPS in GAPS in Risk Lead ID Score Appetite control assurance Score Risk Risk Movement since Sept 2017 our Population improved health and equity for local people 1. Improving population Dr Sohail health and reducing health Abbas inequalities by embedding There is a risk of failure to improve population Strategic the population health health outcomes and to reduce health inequalities clinical director management approach, due to COVID19. Poor outcomes and health of population identifying population inequalities have been highlighted by the COVID19 health and needs and working 1.1 pandemic with both direct and indirect impacts of wellbeing / 16 6 Yes Yes collaboratively with our COVID19 on the economy, education as well as the deputy clinical partners and communities physical health and mental wellbeing of our chair and to implement effective population particularly those living in the areas of Kerry Weir interventions. In order to worst socioeconomic deprivation associate improve health, to promote director of healthy lifestyles and by population Page | 1
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Risk Risk Target Are there Are there
Strategic Objective Risk Strategic Risk Summary Current or GAPS in GAPS in Risk Lead ID Score Appetite control assurance Score Risk Risk Movement since Sept 2017 ensuring access to health health and and care services, wellbeing particularly for those in areas of greatest need 2. Building strong relationships with local There is a risk due to the growing financial authorities and Health and pressures created by an increase in demand for Ali Jan Haider Wellbeing Boards to services could result in agreed strategic and Strategic ensure local priorities for 2.1 operational plans to deliver improved health and director of 16 6 Yes Yes improved health and care care not being realised keeping well at are met by jointly planning, home designing and monitoring the delivery of care our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care 3. Working at Bradford Michelle district and Craven place Turner we will develop and deliver strategic targeted programmes to There is a risk that unwarranted variations in quality director of address the gaps in the and care cannot be effectively addressed due to quality and quality and outcomes of 3.1 shortfalls in workforce capacity, capability and skills nursing and 16 ↔ 4 Yes Yes our health and social care. resulting in failure to close the care and quality gap Gill Paxton We will reduce (across BdC) associate unwarranted variations director of in the quality and care quality and provided for our patients nursing
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Risk Risk Target Are there Are there
Strategic Objective Risk Strategic Risk Summary Current or GAPS in GAPS in Risk Lead ID Score Appetite control assurance Score Risk Risk Movement since Sept 2017 and residents. We will Michelle improve outcomes and Turner experience for our strategic There is a risk that our efforts may not have the patients and residents director of impact we desire due to some determinants of quality and quality and outcomes which lie outside of the 3.2 nursing and 16 9 Yes Yes control of health and social care resulting in a Gill Paxton failure to close the care and quality gap (Quality associate improvement / assurance) director of quality and nursing 4. Working collaboratively at
Bradford district and Vicki Wallace Craven place, our Act As (interim) / One (AAO) way of working Nancy O’Neill improves health and care services whilst ensuring There is a risk that the changes to health services Strategic the clinical and financial models required to achieve clinical and financial director of transformation sustainability of our sustainability are not acceptable to key and change partnership. This will 4.1 stakeholders, e.g. patients, the public or elected 9 ↔ 6 Yes Yes deputy chief include our programmes representatives, and cannot be implemented. This officer and (Access to health and would result in the failure of the act as one care; Respiratory; approach Damien Kay, Diabetes; Healthy Hearts; associate directors of Better births; Ageing Well; transformation and Children and Young
People’s mental wellbeing) and change and enabling strategies
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Risk Risk Target Are there Are there
Strategic Objective Risk Strategic Risk Summary Current or GAPS in GAPS in Risk Lead ID Score Appetite control assurance Score Risk Risk Movement since Sept 2017 5. Develop stronger Vicki Wallace collaborative partnerships (interim) / in local places between the ICP establishment: There is a risk that we fail to Nancy O’Neill NHS, local government gain sufficient organisational traction towards Strategic and others. Including a Integrated Care Partnership for Bradford district and director of central role for primary Craven place, due to a range of factors. This transformation care, collaborative provider 5.1 includes: leadership challenges, failure to agree and deputy 12 ↔ 6 Yes Yes arrangements and governance arrangements and future form and chief officer incorporate strategic function, resulting in failure to achieve a viable form and Damien commissioning through in time to receive delegated responsibilities from the Kay, associate systems with a focus on Integrated Care System directors of population health transformation outcomes and change our People a skilled, motivated workforce with a culture of continuous improvement Liz Allen 6. We will continue to review Strategic and develop our internal ICS people transition: There is a risk of CCG staff director of resources, structures and struggling to adapt to revised system- and organisation processes to ensure that partnership-focussed roles as we move towards the effectiveness, we are able to achieve our new ICS and ICP operating models by 1 April 2022 Fiona Jeffrey strategic objectives as our due to the need for different organisational forms associate commissioning functions 6.1 12 ↔ 8 Yes No and individual CCG staff role flexibility and the director of transfer and, thereby, our normal factors associated with change, organisation CCG staff transition to new exacerbated by the impact of the Covid pandemic effectiveness Integrated Care System upon ways of working, resulting in failure to and Sue (ICS) and Integrated Care successfully transition our CCG staff Baxter Partnership (ICP) strategic head arrangements. of assurance our Leadership assuring the sustainability of our health and care system 7. Working at Bradford There is a risk that we do not address the district and Craven place, 7.1 underlying financial deficit and establish a Robert Maden 16 ↔ 8 Yes No we will maximise value for financially sustainable position over the medium Chief Finance Page | 4
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Risk Risk Target Are there Are there
Strategic Objective Risk Strategic Risk Summary Current or GAPS in GAPS in Risk Lead ID Score Appetite control assurance Score Risk Risk Movement since Sept 2017 money in the use of term as we exit the pandemic Officer healthcare services to ensure we can make shared decisions on how to use our resources to improve population health
The following pages set out the detail the level of risk against each strategic objective the management controls in place and outstanding actions to take as well as the internal and external assurance in place and the outstanding assurances to secure.
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Strategic Risk Log – Risk 1.1 our Population improved health and equity for local people Strategic Objective 1: Improving population health and reducing health inequalities by Risk Lead: Dr Sohail Abbas, strategic clinical director of population health and embedding the population health management approach, identifying population needs wellbeing / deputy clinical chair and working collaboratively with our partners and communities to implement effective Risk Owner: Kerry Weir, associate director of population health and wellbeing interventions. In order to improve health, to promote healthy lifestyles and by ensuring access to health and care services, particularly for those in areas of greatest need. There is a risk of failure to improve population health outcomes and to Specific outcomes: reduce health inequalities due to COVID19. Poor outcomes and health Risk Share responsibility for leading healthier lives and preventing ill health inequalities have been highlighted by the COVID19 pandemic with both rating Create opportunities for people to take control over their own health and direct and indirect impacts of COVID19 on the economy, education as well 16 care as the physical health and mental wellbeing of our population particularly Use population health management solutions in areas with high health those living in the areas of worst socioeconomic deprivation. inequalities (partnerships) Risk Rating Rationale for current score: COVID19 has created significant waiting lists for (Likelihood x services in acute and mental health. The long-term impact on the wider Impact) determinants of COVID19 is still not yet fully understood be we are already seeing increased demand on all sectors. Initial 4 x 4 = 16 Rationale for target score (risk appetite): (Sept 2017) The planning round for 2021/22 is focussed on tackling inequalities, Act-as-One programmes are looking at how Current 5 x 4 = they are tackling inequalities including working with community partnerships. 20 (June 2021) We are monitoring reducing the waiting list based on clinical priorities and ensuring that there are no adverse impacts on those from deprived areas and Target 3 x 2 = 6 ethnicity. RIC focussed work in central Bradford to reduce inequalities in communities.
Partners / stakeholders involved: Patients & patient groups Primary Care Networks and Community Partnerships VCS Act-as-One partners (Bradford district and Craven ‘place’) WYH ICP health inequalities network WYH ICP population health Existing Controls (what are the key controls in place to prevent this risk occurring?) Gaps in Control (where are we failing to put effective controls in place and what more should be done to manage the risk) Act as One initiative overseen via the Health and Care Executive Board Population Health Management system enabling project in early stage of Bradford district & Craven (BdC), Strategy 'happy healthy at home' development (Currently seen by some parties as primarily a health tool, Health & Wellbeing Board and BdC system governance arrangements rather than also applicable to the wider determinants of health) Primary Care Networks Direct Enhanced Service Absence of a clear and credible baseline that indicates the starting Looking at all initiatives from an inequalities perspective (e.g. COVID) position so that any programme progress can be reliably measured
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Strategic Risk Log – Risk 1.1 our Population improved health and equity for local people Strategic Objective 1: Improving population health and reducing health inequalities by Risk Lead: Dr Sohail Abbas, strategic clinical director of population health and embedding the population health management approach, identifying population needs wellbeing / deputy clinical chair and working collaboratively with our partners and communities to implement effective Risk Owner: Kerry Weir, associate director of population health and wellbeing interventions. In order to improve health, to promote healthy lifestyles and by ensuring access to health and care services, particularly for those in areas of greatest need. There is a risk of failure to improve population health outcomes and to Specific outcomes: reduce health inequalities due to COVID19. Poor outcomes and health Risk Share responsibility for leading healthier lives and preventing ill health inequalities have been highlighted by the COVID19 pandemic with both rating Create opportunities for people to take control over their own health and direct and indirect impacts of COVID19 on the economy, education as well 16 care as the physical health and mental wellbeing of our population particularly Use population health management solutions in areas with high health those living in the areas of worst socioeconomic deprivation. inequalities (partnerships) ICS Health Inequalities Academy launched February 2021 Resources at place to support include: BMDC and North Yorkshire Public Health Teams to support the implementation of the programme; CCG Population Health Management team structure now agreed - capacity secured Clear commitment to self-care and prevention by all partners Reducing Inequalities in Communities (RIC) programme and funding targeting the most deprived area in Bradford RIC being launched across WYH ICS as part of Health Inequalities Academy CCG Population Health Management structure implemented April 2021 Controls Action Plan (what actions are being taken to address gaps in Implementation Progress to date control) date 1. Workshop scheduled to begin discussion around Population 26/02/2021 Complete - event held on the 26 February, the terms of reference and Health Management enabling programme (March 2021) membership agreed for the Population Health Management programme – next meeting June 2021. TBC Discussion on wider inequalities and impact on health outcomes. Agreed to 2. Workshop with Wellbeing Board on inequalities create an action plan focusing on education, economic, social, environmental as well as health inequalities and bring back to Wellbeing board in October 18 March 2021 Better Births complete, Ageing Well complete, CVD workshop complete and 3. Act as One programme workshops – PHM/HI presentations respiratory complete.
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Strategic Risk Log – Risk 1.1 our Population improved health and equity for local people Strategic Objective 1: Improving population health and reducing health inequalities by Risk Lead: Dr Sohail Abbas, strategic clinical director of population health and embedding the population health management approach, identifying population needs wellbeing / deputy clinical chair and working collaboratively with our partners and communities to implement effective Risk Owner: Kerry Weir, associate director of population health and wellbeing interventions. In order to improve health, to promote healthy lifestyles and by ensuring access to health and care services, particularly for those in areas of greatest need. There is a risk of failure to improve population health outcomes and to Specific outcomes: reduce health inequalities due to COVID19. Poor outcomes and health Risk Share responsibility for leading healthier lives and preventing ill health inequalities have been highlighted by the COVID19 pandemic with both rating Create opportunities for people to take control over their own health and direct and indirect impacts of COVID19 on the economy, education as well 16 care as the physical health and mental wellbeing of our population particularly Use population health management solutions in areas with high health those living in the areas of worst socioeconomic deprivation. inequalities (partnerships) Assurance Mechanisms (where / how do we get assurance that the existing controls are Assurance Details (specific evidence of positive or negative assurances) working effectively) Internal: PHM enabling programme formally in place from April 2021 but yet to be Ad-hoc reporting on specific initiatives and projects as required - PHM presentation embedded to the CCG Senior Leadership Team in December Performance reporting (not including population health management), to Act as One programmes focussing on health inequalities both the Quality Committee and to the Finance and Performance The 2 Health & Care Partnership Boards have received focussed inequalities Committee presentation from some of the communities across Bradford district and Craven. Process for demonstrating that we are not widening inequalities in order to External: secure elective recovery fund monies (ERF), still needs to be developed Reporting to Health & Wellbeing Board and Act as One Health and Care Executive Board Quarterly whole system review meetings: focus on tackling inequalities Focus on HIs in 2021/22 planning requirements and achievement of Elective Recovery Fund (ERF) Gaps in Assurance & Action Plan where are we failing to gain evidence Implementation Progress to date that our controls are effective and how can we address this? date No routine reporting on health inequalities at CCG nor Act as One Dec 2021 Needs to be part of ICP Inequalities Academy development A place based process needs to be developed to cover 2021/22 Sept 2021 Awaiting ICS guidance planning requirements and ERF by System F&P Need an agreed place based set of HI measures These will be developed as part of District strategy. Inequality action plan, TBC inequality academy, RIC dashboard and health inequalities profiles for ICP transformational programmes will contribute.
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Strategic Risk Log – Risk 1.1 our Population improved health and equity for local people Strategic Objective 1: Improving population health and reducing health inequalities by Risk Lead: Dr Sohail Abbas, strategic clinical director of population health and embedding the population health management approach, identifying population needs wellbeing / deputy clinical chair and working collaboratively with our partners and communities to implement effective Risk Owner: Kerry Weir, associate director of population health and wellbeing interventions. In order to improve health, to promote healthy lifestyles and by ensuring access to health and care services, particularly for those in areas of greatest need. There is a risk of failure to improve population health outcomes and to Specific outcomes: reduce health inequalities due to COVID19. Poor outcomes and health Risk Share responsibility for leading healthier lives and preventing ill health inequalities have been highlighted by the COVID19 pandemic with both rating Create opportunities for people to take control over their own health and direct and indirect impacts of COVID19 on the economy, education as well 16 care as the physical health and mental wellbeing of our population particularly Use population health management solutions in areas with high health those living in the areas of worst socioeconomic deprivation. inequalities (partnerships) Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register Number, brief description, current score (CAF) in February 2021 1.1 Increased national focus commitment to this area – 2021/22 planning & ERF Risk 931: access to and understanding of mental health data (12) Review of previous self-care and prevention programme complete. Risk 1098: failure against key constitutional targets (15) New Living Well Programme launched (new branding, website, resources); new Risk 1582: increased health inequalities (COVID RR) (20) Programme Board and governance structure in place. Additional public health staff supporting the Living Well agenda Reducing Inequalities in Communities launched PHM enabling programme workshop
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Strategic Risk Log – 2.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 2: Building strong relationships with local authorities and Health Risk Lead: Ali Jan Haider, strategic director of keeping well at home and Wellbeing Boards to ensure local priorities for improved health and care are met by Risk Owner: Christina Holloway, associate director of keeping well jointly planning, designing and monitoring the delivery of care There is a risk due to the growing financial pressures created by an Specific outcomes: Risk increase in demand for services could result in agreed strategic and Make shared decisions on how to use our resources to improve population rating operational plans to deliver improved health and care not being realised. health 16 Look beyond health to where we can make the greatest difference to the wellbeing of local people Risk Rating Rationale for current score: (Likelihood x Financial pressures impacting on relationships and the ability to jointly Impact) commission services is considered fairly likely, with a moderate impact. Following on from COVID19 the impact on finances remains challenging during Initial 3 x 3 = 9 our recovery. (Sept 2017) Rationale for target score (risk appetite): Current 4 x 4 = 16 We believe we can reduce the likelihood of the risk by focussing on the (June 2021) benefits to users and business benefits for partners of closer working.
Target 2 x 3 = 6 Partners / stakeholders involved: • Local Authority • VCS • Patient Groups
Existing Controls what are the key controls in place to prevent this risk occurring? Gaps in Control where are we failing to put effective controls in place and what more should be done to manage the risk Wellbeing Board membership including non-health and social care representatives Unpredictability of financial pressures impacting on partner organisations Joint working with CBMDC and collaboration with a wide variety of stakeholders Lack of transparency and openness regarding the impact of funding and Agreement to the principles of ‘no cost shunting’ decommissioning decisions Living Well programme plan and Living Well programme board and collaborative Reduction in true spend on self-care and prevention Early help and prevention programme board Key priorities of Living Well to be re-determined (with need for fundamental Personalised Commissioning / Continuing Healthcare – differences in approaches analysis of the impact of COVID to support this) and working practices identified between health and social care. Joint policy is in Limited training for staff in motivational interviewing and normalising self- development care Agreed process for considering shared responsibilities for children placed in Personalised commissioning and continuing health care joint policy educational establishments out-of-area (is under review) Review of process for shared responsibilities in relation to placed children Page | 10
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Strategic Risk Log – 2.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 2: Building strong relationships with local authorities and Health Risk Lead: Ali Jan Haider, strategic director of keeping well at home and Wellbeing Boards to ensure local priorities for improved health and care are met by Risk Owner: Christina Holloway, associate director of keeping well jointly planning, designing and monitoring the delivery of care There is a risk due to the growing financial pressures created by an Specific outcomes: Risk increase in demand for services could result in agreed strategic and Make shared decisions on how to use our resources to improve population rating operational plans to deliver improved health and care not being realised. health 16 Look beyond health to where we can make the greatest difference to the wellbeing of local people Controls Action Plan what actions are being taken to address gaps in Implementation Progress to date control date 1. Continue to influence partners and negotiate practical Joined up conversations at the Health and Care Partnership Boards to tackle solutions in regards to the unpredictability of financial together the financial challenges. 31 March 2022 pressures System conversations between adult social care and the CCG regarding funding for care home sector and the Better Care Fund. 2. Address the lack of transparency and openness regarding We have responded regularly to the BMDC councils budget, consultations funding and decommissioning decisions processes, highlighting areas of concern and potential negative impact for At least annually by health services locally. 31 March 2022 We have also responded to North Yorkshire County Council on budget decisions which have a potential adverse impact on health services in BdC. 3. Analysis of the impact of COVID to re-determine priorities for The Living Well programme has a number of priorities that address key areas the Living Well programme of self-care and prevention. The enabling delivery projects have been revised following COVID and the priorities include childhood obesity, Living Well Completed Schools, Living Well training academy, Living Well service, Living Well communications, stakeholder engagement, Living Well businesses and strategic approaches to physical activity, 4. Resolve the limited training available for staff in motivational The contract for the motivational interviewing training has ended in March 2021 interviewing and normalising self-care but the new Living Well Academy is currently being established which will offer Completed a wide range of training opportunities to support communities, schools, health and social care staff and local businesses. 5. Personalised commissioning and continuing health care joint Procedures have been reviewed for CHC via a CHC Operational and CHC policy in place In place Strategic Oversight Group. In addition, a Children’s Continuing Care Verification Group is now in place to ensure agreements between health and social care are correct, CCC process is sound with appropriate care resource being commissioned appropriately.
1 November 2021 We are currently undergoing a review of children’s CCC & PHB procedures using audit recommendations – to be completed by 1 November 2021 6. Complete the review of the process for shared responsibilities Completed This action has been completed for children looked after through the Joint Page | 11
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Strategic Risk Log – 2.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 2: Building strong relationships with local authorities and Health Risk Lead: Ali Jan Haider, strategic director of keeping well at home and Wellbeing Boards to ensure local priorities for improved health and care are met by Risk Owner: Christina Holloway, associate director of keeping well jointly planning, designing and monitoring the delivery of care There is a risk due to the growing financial pressures created by an Specific outcomes: Risk increase in demand for services could result in agreed strategic and Make shared decisions on how to use our resources to improve population rating operational plans to deliver improved health and care not being realised. health 16 Look beyond health to where we can make the greatest difference to the wellbeing of local people in relation to children in educational establishments out-of- Placement Panel. All agreements are made jointly through this panel. Terms of area reference and memorandum of understanding have been agreed and current agreements are being reviewed following ongoing developments within ‘act as one’ and to further embed system agreements Assurance Mechanisms where / how do we get assurance that the existing controls are Assurance Details specific evidence of positive or negative assurances working effectively Reports and updates to Bradford Wellbeing Board The consultation on the budget describes in detail the commissioning and Minutes of CBMDC Executive meeting in relation to plans, funding and service decommissioning for the coming year. Currently awaited for 2021/22. changes Reports to the Health and Care Executive Board Reports to HOSC and the Wellbeing Board Annual BMDC budget consultation Gaps in Assurance & Action Plan where are we failing to gain Implementation Progress to date evidence that our controls are effective and how can we address this? date 1. No regular reporting to Governing Body on the Living Well The chief executive report which will highlight any significant achievements or In place programme active concerns within the act-as-one programmes (including the living well
programme) Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register number, brief description, current score) (CAF) in February 2021 1.1 We have seen a growing demand for children’s autism assessments and services. We Risk 1101: health input to education & care plans (SEND) (12) anticipate an increase in demand both on primary and secondary care services following Risk 1094: child autism / ADHD services (16) easing of lockdown post COVID19, leading to an impact on finances which remains Risk 1134: health outcomes of children looked after (12) challenging during our and in the coming year(s). Risk 1135: adult autism / ADHD services (16) Risk 1404: 0-19 services; impact on CCG commissioned services (15) Risk 1613: demand for mental health services outweighs capacity (25)
Note for corporate risk cycle 2: potential new risk: demand for health and care services increased post-covid and through easing of lockdown
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Strategic Risk Log – 3.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working at Bradford district and Craven place we will develop Risk Lead: Michelle Turner, strategic director of quality and nursing and deliver targeted programmes to address the gaps in the quality and outcomes of our Risk Owner: Gill Paxton, associate director of quality and nursing, Damien health and social care. We will reduce unwarranted variations in the quality and care Kay, associate director of transformation and change & Dawn Clissett, senior provided for our patients and residents. We will improve outcomes and experience head of strategy, change and delivery for our patients and residents Risk There is a risk that unwarranted variations in quality and care cannot be Specific outcome: rating effectively addressed due to shortfalls in workforce capacity, capability Improve our skills and knowledge to increase our personal value 16 and skills resulting in failure to close the care and quality gap (across BdC) Risk Rating Rationale for current score: (Likelihood x Impact) Attrition rates and sickness absence is higher and expressions of workforce are related to a workforce who are struggling with fatigue. The national drive Initial 4 x 4 = 16 (Sept and ambition to recruit nursing workforce has lagged in delivery. Recruitment is 2017) slower to fill the increasing workforce gaps across Bradford District and Craven. Current 4 x 4 = 16 (June 2021) Rationale for target score (risk appetite): Ongoing local challenges in recruitment and retention of a skilled workforce Target 2 x 2 = 4 continue to be reported across the Health Care Partnership systems. It is likely that this will continue, risking sustainability for some services. Due to the development of the Commissioning People Plan, a Bradford District and Craven wide primary care workforce together with acute/mental health and community provider workforce plans, we anticipate that workforce initiatives and movement across the health care partnership provider system delivery structures will reduce the likelihood and impact of any shortfalls within the system. Additionally further initiatives across primary care such as GP and Practice Nurse leadership schemes that have been held over the last year are beginning to yield strengthened leadership and therefore address variations in practice.
Partners / stakeholders involved: GP Practices and Primary Care Networks Health Care Partnership Board stakeholders (AWC and Bradford HCP’s) Demand needs to be owned by all stakeholders in the footprint NHS England WY stakeholders. HEE
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Strategic Risk Log – 3.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working at Bradford district and Craven place we will develop Risk Lead: Michelle Turner, strategic director of quality and nursing and deliver targeted programmes to address the gaps in the quality and outcomes of our Risk Owner: Gill Paxton, associate director of quality and nursing, Damien health and social care. We will reduce unwarranted variations in the quality and care Kay, associate director of transformation and change & Dawn Clissett, senior provided for our patients and residents. We will improve outcomes and experience head of strategy, change and delivery for our patients and residents Risk There is a risk that unwarranted variations in quality and care cannot be Specific outcome: rating effectively addressed due to shortfalls in workforce capacity, capability Improve our skills and knowledge to increase our personal value 16 and skills resulting in failure to close the care and quality gap (across BdC) Existing Controls (what are the key controls in place to prevent this risk occurring?) Gaps in Control where are we failing to put effective controls in place and what more should be done to manage the risk Wellbeing Board and West Yorkshire ICS A lack of a consistent approach to understanding return on investment Health and Care Executive Commissioning Board including investment of all resources (staff and money) Finance and Performance Committee and performance report and Quality Due to HEE allocation in education credits to HEI’s, the CCGs have noted Committees (CCG and System) and quality reporting the curtailment/limitation to relevant health courses available locally, this Integrated People Board (IPB)/ Primary care strategy – Provider led including will likely continue to impact in the short term of the availability of a local representation from BCA. skilled workforce – outside of CCG control but we will try to influence in this West Yorkshire Quality Surveillance Group (includes regulators) area by assessing workforce plans and skill gaps to inform further West Yorkshire and Harrogate People Board and associated groups in place discussions Development of the Commissioning People Plan Challenges in enabling and facilitating free movement across the system of Health and Social Care Economic Partnership qualified and capable staff have resulted in little uptake from staff within the local system. No mechanism to balance the allocation of sufficient Strategic Coordination Group – attended by Public Health colleagues resource to local requirements due to national shortage of skilled workforce An agreement /MoU underpinning the movement of staff within the Health Care / allocations competing priorities. The new Government White Paper Partnership outlining the development of ICS/ICP’s may affect the ability of the system The WYAAT trusts have signed an agreement that enables colleagues who are to recruit suitably qualified staff competent to undertake roles and are cleared to work in one of our organisations to Inability to view the performance of the entire pathway due to unavoidable be able to work in another WYAAT trust without the need for an honorary contract data constraints (e.g., legal and information governance requirements) and all the associated checks Controls Action Plan Implementation Progress to date (what actions are being taken to address gaps in control) date 1. Discussions are ongoing with HEE and HEIs to identify priority April 2022 Primary Care workforce are now represented (via the Primary Care Workforce areas and agree engagement required when such decisions are and Training Hub) at the Bradford University Workforce Needs meeting and made, to ensure sustainability of local care services. also the work currently being undertaken to increase the number and quality of clinical placements across the system. Primary Care workforce needs were fed into the refreshed BD & C Integrated People Plan which will continue to be a ‘live’ document. All additional training needs have been fed into the Transformation Training Requirements for 2021/22 for WY/HEE and for the successful bids against the SSWDF to enable commissioning of education and Page | 14
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Strategic Risk Log – 3.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working at Bradford district and Craven place we will develop Risk Lead: Michelle Turner, strategic director of quality and nursing and deliver targeted programmes to address the gaps in the quality and outcomes of our Risk Owner: Gill Paxton, associate director of quality and nursing, Damien health and social care. We will reduce unwarranted variations in the quality and care Kay, associate director of transformation and change & Dawn Clissett, senior provided for our patients and residents. We will improve outcomes and experience head of strategy, change and delivery for our patients and residents Risk There is a risk that unwarranted variations in quality and care cannot be Specific outcome: rating effectively addressed due to shortfalls in workforce capacity, capability Improve our skills and knowledge to increase our personal value 16 and skills resulting in failure to close the care and quality gap (across BdC) training on a needs led basis. The Bradford Care Alliance organised a workforce system development day in February 2020 to engage on key priority areas for primary care for 2020/1 and a focus on Primary Care Workforce will be presented at the INTEGRATED PEOPLE BOARD (IPB) in March 2021. 2. Raise with the WYQSG and local CCGs across the HCP April 2022 Raised at WYQSG, DoN forum, primary and Community Care HCP workgroup. footprint, approach to workforce challenges Challenges and workforce needs fed into the BD & C Integrated People Plan and primary care has a regular place at the Integrated People Board (IPB). Portability of staffing across the WYAAT is in place to support enabling recognition of employment check and mandatory training and thus releasing more clinical input into the system and a staff sharing MoU was developed in response to the Covid19 pandemic. Greater opportunities to ‘market’ the attractiveness of working in Bradford District and Craven via the health and care economic partnership and our Growing for the Future programme of work in the IPP will continue to a core area of work in the months ahead. Assurance Mechanisms Assurance Details where / how do we get assurance that the existing controls are working effectively specific evidence of positive or negative assurances Integrated People Board discussion and reporting shared with System Quality Gap in assurance until there is a coordinated workforce system plan Committee, CCG Quality Committee (JQC) and programme work streams against which to measure progress. Reporting of gaps in care and workforce challenges across our providers reported Ongoing development of the system strategy for BdC place is underway as monthly to the System Quality Committee part of the ICP establishment, within which people is a work stream and Quality assurance mechanisms of providers identify gaps and workforce challenges ambition. and agreement of actions required in place Quality assurance and performance monitoring to address care delivery gaps actioned via provider contractual meetings including use of incentives such as CQUINS is in place / CQC inspections Gaps in Assurance & Action Plan (where are we failing to gain evidence Implementation Progress to date that our controls are effective and how can we address this?) date 1. Reporting against the system plan to Integrated People Board TBC Reporting against the system plan to IPB and Health Care partnerships (HCP) (IPB) and Health Care partnerships (HCP) x 2. x 2. 2. Implementation and use of refined integrated dashboards across April 2022 Building on the LTP narrative produced in 2019 and the integrated dashboard Page | 15
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Strategic Risk Log – 3.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working at Bradford district and Craven place we will develop Risk Lead: Michelle Turner, strategic director of quality and nursing and deliver targeted programmes to address the gaps in the quality and outcomes of our Risk Owner: Gill Paxton, associate director of quality and nursing, Damien health and social care. We will reduce unwarranted variations in the quality and care Kay, associate director of transformation and change & Dawn Clissett, senior provided for our patients and residents. We will improve outcomes and experience head of strategy, change and delivery for our patients and residents Risk There is a risk that unwarranted variations in quality and care cannot be Specific outcome: rating effectively addressed due to shortfalls in workforce capacity, capability Improve our skills and knowledge to increase our personal value 16 and skills resulting in failure to close the care and quality gap (across BdC) providers are to include required detail regarding workforce and approach, the BD & C Planning Forum is meeting fortnightly to ensure the coordinated approach to quality assurance and workforce locally triangulation of NHS money, activity and workforce across ‘place’. Its focus is across delegation of primary care to identify clear workforce gaps looking at the reset and recovery planning requirements, against a backdrop of and priority areas. the Covid19 pandemic and the need for transformation of agreed pathways and development of new models of care – planning guidance is still waited for 2021/22. During 2020 the system workforce strategy was developed into an Integrated People Plan to reflect the 4 programmes of work in the NHS People Plan. The delivery plan to underpin this is being developed with key programme leads and clear priorities for the next 12 months and 1-3 years. Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register number, brief description, current score (CAF) in February 2021 1.1 Bradford district and Craven Integrated People plan developed and delivery is No related risks on the corporate risk register overseen by Integrated People Board, with submission of NHS Priorities and Operational Planning 2021/22 workforce narrative including plans/data explained in terms of assumptions, actions, risks & issues for primary care, acute, community, ambulance and mental health. Greater connectivity with primary medical care and neighbourhoods System passport for care agreed for ‘place’ Greater alignment with health and care economic partnership to ‘market’ Bradford and Craven
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Strategic Risk Log – 3.2 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working collaboratively, we will develop and deliver targeted Risk Lead: Risk Lead: Michelle Turner, strategic director of quality and programmes to address the gaps in the quality and outcomes of our health and social nursing care. We will reduce unwarranted variations in the quality and care provided for our Risk Owner: Gill Paxton, associate director of quality and nursing patients and residents. We will improve outcomes and experience for our patients and (supported by John Hartley, Head of Patient Outcomes) residents. Specific outcome: Risk There is a risk that our efforts may not have the impact we desire due to rating some determinants of quality and outcomes which lie outside of the control Through our partnerships, reduce the variation in people’s experience of the care and quality 16 of health and social care resulting in a failure to close care gap (Quality improvement / assurance) Risk Rating The impact of COVID19 on long term conditions, identification of conditions (Likelihood x Impact) such as cancer through lack of early presentation. Rise in frailty due to long term isolation and increases in mental health issues. Waiting times for Initial 4 x 4 = 16 diagnostics and planned care activity have increased over the period of the (Sept 2017) pandemic.
Current 4 x 4 = 16 Further cooperation between partners (see below) and more joined up system (June 2021) wide plans for improvement i.e. Act as One, ICS and ICP, system performance and quality groups are working towards reducing the likelihood of the risk Target 3 x 3 = 9 occurring, and improved the way we mitigate the risk.
Rationale for target score (risk appetite): The impact of not closing the care and quality gap will always remain high but we expect long term interventions will likely reduce the gap. NHS 10 Year Plan signals more involvement / influence of NHS bodies in the wider determinants of quality and outcomes.
Partners / stakeholders involved: BDMC and NYCC Health care Partnerships x 3 BPA BCA NHSE and NHSI VCS BDCFT BTHFT / ANHSFT ICS CPs / PCNs
ICP Independent Sector Partners Existing Controls what are the key controls in place to prevent this risk occurring? Gaps in Control where are we failing to put effective controls in place and what more should be done to manage the risk EQIA process Long term outcomes affected by wider determinants of health, Serious Incident review process demographic and societal issues i.e. housing, debt, air quality Patient experience process System Quality Assurance framework Page | 17
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Strategic Risk Log – 3.2 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working collaboratively, we will develop and deliver targeted Risk Lead: Risk Lead: Michelle Turner, strategic director of quality and programmes to address the gaps in the quality and outcomes of our health and social nursing care. We will reduce unwarranted variations in the quality and care provided for our Risk Owner: Gill Paxton, associate director of quality and nursing patients and residents. We will improve outcomes and experience for our patients and (supported by John Hartley, Head of Patient Outcomes) residents. Specific outcome: Risk There is a risk that our efforts may not have the impact we desire due to rating some determinants of quality and outcomes which lie outside of the control Through our partnerships, reduce the variation in people’s experience of the care and quality 16 of health and social care resulting in a failure to close care gap (Quality improvement / assurance) A more direct influence on system wide quality, performance, and outcomes through System agreement on prioritisation of resources to address safety issues joint working; SPA, SF&PC, SQC etc. specific funding allocated to reduce Lack of sight of the proportion of EU nationals registered within BdC with / inequalities through i.e. RIC without settled status and the impact on their right to access NHS services Act as One system programmes and WYH ten ambitions beyond June 2021 Further clinical engagement with primary care via the Clinical Forum Corporate and COVID risk registers West Yorkshire Quality Surveillance Group (includes regulators) CCG Finance and Performance Committee and Quality Committee BdC system Finance and Performance Committee and system Quality Committee CCG Plans to close gap signed off by Governing Bodies Assurance of plans by NHS England / NHS Improvement Work at a Locality and Community Partnership level with partner organisations to understand and look to meet more specific local need Focus on Population Health through specific group within the commissioning function (PHW Hub) Programmes jointly undertaken with Public Health to improve wider determinants of health Controls Action Plan what actions are being taken to address gaps in Implementation Progress to date control date 1. No existing agreed action plan is in place; however we anticipate October 2021 CCGs continue to explore how best to close the care quality gap through that a combination of sector action and response to improve the system partnership plans overseen by local partnership arrangements, Clinical health, well-being, social determinants/living standards and Forum, Exec Board, WB. employability will over time impact positively to improve outcomes for the people of Bradford and Airedale localities. 2. System QA/QI framework for agreement by System Quality October 2021 QA/QI framework discussion on Agenda for SQC in Feb 2021 meeting. Committee Feb 2021 and then to be rolled out incrementally Agreement to be reached across all place partners on the QA/QI framework by October 2021
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Strategic Risk Log – 3.2 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working collaboratively, we will develop and deliver targeted Risk Lead: Risk Lead: Michelle Turner, strategic director of quality and programmes to address the gaps in the quality and outcomes of our health and social nursing care. We will reduce unwarranted variations in the quality and care provided for our Risk Owner: Gill Paxton, associate director of quality and nursing patients and residents. We will improve outcomes and experience for our patients and (supported by John Hartley, Head of Patient Outcomes) residents. Specific outcome: Risk There is a risk that our efforts may not have the impact we desire due to rating some determinants of quality and outcomes which lie outside of the control Through our partnerships, reduce the variation in people’s experience of the care and quality 16 of health and social care resulting in a failure to close care gap (Quality improvement / assurance) 3. System agreement on prioritisation of resources to address May 2021 System Planning Forum and System Strategy Group work focus on joined up safety issues through planning and prioritisation processes and (completed) planning processes and a consistent approach to prioritising the use of governance protocols supported by system partners i.e. Planning Signoff by resource to maximise returns around funding, quality of service provision, and Forum. F&PC, SQC, System Strategy Group September 21 improved outcomes for the population Assurance Mechanisms where / how do we get assurance that the existing controls are Assurance Details specific evidence of positive or negative assurances working effectively Internal: NHS System Oversight Framework – TBC once released Monthly reporting to SLT and to CCG Quality Comm. and System Quality Comm. National Quality Board have released a draft dashboard. Final version is Quality report to Governing Body (bi-monthly) yet to be released – TBC once released Monthly Primary Care contract assurance and contract management groups (CAG & PCCC) Risk Register to include ongoing risk regarding quality of service provision – reviewed as part of the risk cycle
External: Regulators (CQC, NHSE/I, OFSTED, MHRA and HSE etc) Safeguarding Boards Overview and Scrutiny Committee Gaps in Assurance & Action Plan where are we failing to gain evidence Implementation Progress to date that our controls are effective and how can we address this? date Reporting and assurance arrangements to be developed in Ongoing – to The CCG Programme Office and the Deputy Director of Performance are partnership with stakeholder organisations to ensure that the health review February developing a common reporting framework to provide assurance, which will of the population is adequately measured / March 2021 include progess against outcomes.
Approach to Quality assurance and reporting of quality of service provision under review via the System Quality Committee
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Strategic Risk Log – 3.2 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 3: Working collaboratively, we will develop and deliver targeted Risk Lead: Risk Lead: Michelle Turner, strategic director of quality and programmes to address the gaps in the quality and outcomes of our health and social nursing care. We will reduce unwarranted variations in the quality and care provided for our Risk Owner: Gill Paxton, associate director of quality and nursing patients and residents. We will improve outcomes and experience for our patients and (supported by John Hartley, Head of Patient Outcomes) residents. Specific outcome: Risk There is a risk that our efforts may not have the impact we desire due to rating some determinants of quality and outcomes which lie outside of the control Through our partnerships, reduce the variation in people’s experience of the care and quality 16 of health and social care resulting in a failure to close care gap (Quality improvement / assurance) Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register number, brief description, current score (CAF) in February 2021 1.1 Assurance provided to System Quality Committee & CCG Quality Committee. Risk 940: BTHFT quality and safety of maternity services (16) Challenge regarding impacts to and on quality of service provision through updates Risk 943: COVID19 impact on care home quality (COVID RR Score 16) and deep dive analysis Risk 1036: quality of stroke care services (8) System Programmes delivering against identified priorities at a local level (including Risk 1312: quality of primary care (8) Act as One programmes) which include impacts on outcomes as a result of identified deliverables System EQIA process utilised to highlight positive and negative impact of proposed service change and identify areas of potential focus for programmes Serious Incident review process utilised to highlight areas for improvement including themes and trends – monthly reporting to Quality Committee and Senior Leadership Team as appropriate Patient experience process utilised to highlight areas of excellence and poor service quality – fed into programmes, Quality Committee and Senior Leadership Team as appropriate. Plan to widen the scope to include partner organisation’s patient feedback and report to System Quality Committee System QA framework being implemented on an incremental basis to provide assurance on provider service provision- to System Q comm. Feb/March 2021 Links to Population Health Management reporting and data availability to highlight areas for improvement Use of PC data dashboard to highlight variation in practice at PCN & Practice level
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Strategic risk log - Risk 4.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 4: Working collaboratively at Bradford district and Craven place, our Risk Lead: Vicki Wallace (interim) / Nancy O’Neill, Strategic director of Act As One (AAO) way of working improves health and care services whilst ensuring the transformation and change deputy chief officer / clinical and financial sustainability of our partnership. This will include our programmes Risk Owner: Vicki Wallace & Damien Kay, associate directors of (Access to health and care; Respiratory; Diabetes; Healthy Hearts; Better births; Ageing transformation and change Well; and Children and Young People’s mental wellbeing) and enabling strategies Supported by: Act as one Programme Team There is a risk that the changes to health services models required to Specific outcomes Risk achieve clinical and financial sustainability are not acceptable to key use population health management in areas experiencing high deprivation rating stakeholders, e.g. patients, the public or elected representatives, and facilitate health and care to become more joined up and coordinated 9 cannot be implemented. This would result in the failure of the act as one around people approach. reduce unwarranted variation in people’s experience of care Risk Rating Rationale for current score: (Likelihood x Impact) Due to the response to the COVID19 pandemic programmes had been scaled back and refocussed to provide support for the response locally. Further to Initial 3 x 4 = 12 this the act as one programmes did a further reflection on their scope to ensure (Sept 2017) they were focused on addressing inequalities – which strengthens the connection to two of the ‘specific outcomes – PHM and reducing unwarranted Current risk 3 x 3 = 9 variation. We have also submitted our system plan for recovery (assurance). (June 2021) Rationale for target score (risk appetite): Target 2 x 3 = 6 We seek to reduce the likelihood and impact
Partners / stakeholders involved: All signatories to the SPA, plus general practices
Existing Controls Gaps in Control where are we failing to put effective controls in place and what more what are the key controls in place to prevent this risk occurring? should be done to manage the risk System governance structure, with oversight via ICP Executive Board includes a Chairs and elected members reference group to be established to guide system Finance and Performance Committee, a system Quality Committee and the ICP development with the aim of providing additional assurance for Health and Care Partnership Boards non-executives and elected members to be aware and support the Strategic Partnering Agreement in place and being reviewed to reflect current ways changes in relation to ICP development of working To align with legislative changes a new refresh of the SPA from 1 April Act as one strategic communications plan 2022 onwards Act as One initiative in place with programmes (Access to health and care, BdC assurance / risk management framework, to be in place from October
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Strategic risk log - Risk 4.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 4: Working collaboratively at Bradford district and Craven place, our Risk Lead: Vicki Wallace (interim) / Nancy O’Neill, Strategic director of Act As One (AAO) way of working improves health and care services whilst ensuring the transformation and change deputy chief officer / clinical and financial sustainability of our partnership. This will include our programmes Risk Owner: Vicki Wallace & Damien Kay, associate directors of (Access to health and care; Respiratory; Diabetes; Healthy Hearts; Better births; Ageing transformation and change Well; and Children and Young People’s mental wellbeing) and enabling strategies Supported by: Act as one Programme Team There is a risk that the changes to health services models required to Specific outcomes Risk achieve clinical and financial sustainability are not acceptable to key use population health management in areas experiencing high deprivation rating stakeholders, e.g. patients, the public or elected representatives, and facilitate health and care to become more joined up and coordinated 9 cannot be implemented. This would result in the failure of the act as one around people approach. reduce unwarranted variation in people’s experience of care Respiratory, Diabetes, Healthy Hearts, Better births, Ageing Well, Children and 2021 (shadow) Young People’s mental wellbeing) ICP system development plan, will concurrently through 2021/22 (work Years of collaboration and relationship building that has been further enhanced by streams: (i) leadership & behaviours and (ii) communications & COVID19 response engagement with the latter focused upon co-production where possible, and engagement of the public in all cases) Controls Action Plan what actions are being taken to address gaps in Implementation Progress to date control date Completed the refresh and out for signature and adoption by each partner 1. Complete SPA refresh March 2021 through their governance arrangements Sharing of the SPA partners assurance framework pulled together into one 2. BdC risk management framework inc AF and RRs From October document (Paul Hogg) (shadow) and in
place from 1 Subsumed the risk management framework and arrangements within the ICP April 2022 establishment governance work stream. We will start to provide monthly reporting from the ICP development 3. ICP system development plan Ongoing programme board to the ICP executive board including articulation of priority through 2021/22 areas in place and commenced. Further iterations and connectivity across ICP development work streams is to be explored and an interdependencies matrix for the work streams drawn up. Assurance Mechanisms where / how do we get assurance that the existing controls are Assurance Details specific evidence of positive or negative assurances working effectively Internal: Slimmed down Act as One programme updates provided throughout Monthly report on Act as One to the CCG Senior Leadership Team COVID19 pandemic with satisfactory progress towards key milestones for Monthly System & Place (ICS and ICP) report to the CCG Senior Leadership Team the refocussed programmes. Chief Officer's Report to Governing Body visibility of enabling strategies
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Strategic risk log - Risk 4.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Strategic Objective 4: Working collaboratively at Bradford district and Craven place, our Risk Lead: Vicki Wallace (interim) / Nancy O’Neill, Strategic director of Act As One (AAO) way of working improves health and care services whilst ensuring the transformation and change deputy chief officer / clinical and financial sustainability of our partnership. This will include our programmes Risk Owner: Vicki Wallace & Damien Kay, associate directors of (Access to health and care; Respiratory; Diabetes; Healthy Hearts; Better births; Ageing transformation and change Well; and Children and Young People’s mental wellbeing) and enabling strategies Supported by: Act as one Programme Team There is a risk that the changes to health services models required to Specific outcomes Risk achieve clinical and financial sustainability are not acceptable to key use population health management in areas experiencing high deprivation rating stakeholders, e.g. patients, the public or elected representatives, and facilitate health and care to become more joined up and coordinated 9 cannot be implemented. This would result in the failure of the act as one around people approach. reduce unwarranted variation in people’s experience of care External Whole system quarterly review with NHSE / I and WY&H ICS Bradford Wellbeing Board monitor progress against the metrics developed by LGA Minutes of Bradford Wellbeing Board Attendance at Overview and Scrutiny Committees Internal audit of programme management arrangements (significant assurance) Gaps in Assurance & Action Plan where are we failing to gain Implementation Progress to date evidence that our controls are effective and how can we address this? date Chief officer reports on progress update to SLT and GB 1. Act-as-one programme updates In-place Conversations commenced with health and care partnership leaders for the 2. Address visibility of enabling strategies By October 2021 most appropriate reporting route for enabling strategies Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register (number, brief description, current (CAF) in February 2021 score): 1.1 Internal audit issued report showing significant assurance Risk 1872: Elective Recovery Fund depends on performance of all SPA refresh completed and signed off by all signatory partner boards organisations across WY (16) AAO Festival held to showcase examples of AAO working Leadership and behaviours work stream of ICP establishment programme identifies interventions to further develop culture and ethos of AAO as way of working
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Strategic Risk Log – Risk 5.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Risk Lead: Vicki Wallace (interim) / Nancy O’Neill Strategic Objective 5: Develop stronger collaborative partnerships in local places Strategic director of transformation and change deputy chief officer between the NHS, local government and others. Including a central role for primary care, Risk Owner: Vicki Wallace & Damien Kay, associate directors of collaborative provider arrangements and incorporate strategic commissioning through transformation and change systems with a focus on population health outcomes Supported by: James Drury, Programme Director Executive Board ICP establishment: There is a risk that we fail to gain sufficient Specific outcomes: Risk organisational traction towards Integrated Care Partnership for Bradford use population health management in areas experiencing high deprivation rating district and Craven place, due to a range of factors. This includes: facilitate health and care to become more joined up and coordinated 12 leadership challenges, failure to agree governance arrangements and future around people form and function, resulting in failure to achieve a viable form in time to reduce unwarranted variation in people’s experience of care receive delegated responsibilities from the Integrated Care System Risk Rating Rationale for current score: (Likelihood x Impact) Programme structure has been established, however resources for the work streams have still not been fully identified. An ICP programme board Initial 4 x 3 = 12 was initiated in May 2021 but requires time and resource to deliver against (February 2021) a broad range of work streams related to vision and strategy, leadership and behaviour, design and delivery. Greater clarity is required as to the 4 x 3 = 12 future operating model for the ICP in order to understand the potential June 2021 impact on all work streams.
Target 3 x 2 = 6 Rationale for target score (risk appetite): We seek to reduce the likelihood and impact
Partners / stakeholders involved: All signatories to the SPA, plus general practices Functions need to be agreed at ICS level and dependent on the ICS programme
Existing Controls what are the key controls in place to prevent this risk occurring? Gaps in Control where are we failing to put effective controls in place and what more should be done to manage the risk ICP Exec Board will be assured by the ICP Establishment Programme Board HM Gov white paper outlines the proposals to legislative changes affording ICP Establishment Programme Board (meeting every two weeks from the end of the statutory basis to form ICS and ICPs, however the detail isn’t yet clear. May is accountable to the ICP Exec Board. Timeline is unclear due to passage of the ICS legislation through Regular management meetings with each work stream lead (fortnightly/monthly) parliament. (leading to needing clarity of a shared understanding of where Each work stream has a job card and work stream definition, with associated straw we need to be and by when) man to enable delivery of the job card Strategic Partnering Agreement in place, being refreshed to be completed by March ICP Establishment Programme Board Terms of Reference to be drafted Page | 24
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Strategic Risk Log – Risk 5.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Risk Lead: Vicki Wallace (interim) / Nancy O’Neill Strategic Objective 5: Develop stronger collaborative partnerships in local places Strategic director of transformation and change deputy chief officer between the NHS, local government and others. Including a central role for primary care, Risk Owner: Vicki Wallace & Damien Kay, associate directors of collaborative provider arrangements and incorporate strategic commissioning through transformation and change systems with a focus on population health outcomes Supported by: James Drury, Programme Director Executive Board ICP establishment: There is a risk that we fail to gain sufficient Specific outcomes: Risk organisational traction towards Integrated Care Partnership for Bradford use population health management in areas experiencing high deprivation rating district and Craven place, due to a range of factors. This includes: facilitate health and care to become more joined up and coordinated 12 leadership challenges, failure to agree governance arrangements and future around people form and function, resulting in failure to achieve a viable form in time to reduce unwarranted variation in people’s experience of care receive delegated responsibilities from the Integrated Care System 2021 and agreed System governance structure, with oversight via ICP Executive Board includes a Chairs and elected members reference group to be established to guide system Finance and Performance Committee, a system Quality Committee and the ICP development with the aim of providing additional assurance for Health and Care Partnership Boards non-executives and elected members to be aware and support the WY&H ICS are developing an ICP Development Framework (led by Helen Hirst) - changes in relation to ICP development first draft due April 2021 - to be implemented at each of the five places that make up Detailed establishment programme and organisational/way of working WY ICS (version 7 avail) approach is defined and will need to be aligned with ICS legislation. Programme structure and programme management approach to be established including action log. To align with legislative changes a new refresh of the SPA from 1 April 2022 onwards ICP assurance / risk management framework - to be developed by October 2021 ICP system development plan, will concurrently through 2021/22 (work streams: (i) leadership & behaviours and (ii) communications & engagement) Internal audit report highlighted no mechanisms currently in place to measure outcome of AAO programmes. This is currently under discussion by Programme Directors to mitigate Controls Action Plan what actions are being taken to address gaps in Implementation Progress to date control date 1. ICP Establishment Programme Board terms of reference to be ICP Programme Director drafting the terms of reference 31 July 2021 drafted, agreed and signed off by ICP Exec Board 2. Establishment of PMO approach to manage the establishment of Core PMO office being established to support ICP Programme Director and we the ICP establishment 30 June 2021 have identified an Executive sponsor, SRO and management lead for each work stream
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Strategic Risk Log – Risk 5.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Risk Lead: Vicki Wallace (interim) / Nancy O’Neill Strategic Objective 5: Develop stronger collaborative partnerships in local places Strategic director of transformation and change deputy chief officer between the NHS, local government and others. Including a central role for primary care, Risk Owner: Vicki Wallace & Damien Kay, associate directors of collaborative provider arrangements and incorporate strategic commissioning through transformation and change systems with a focus on population health outcomes Supported by: James Drury, Programme Director Executive Board ICP establishment: There is a risk that we fail to gain sufficient Specific outcomes: Risk organisational traction towards Integrated Care Partnership for Bradford use population health management in areas experiencing high deprivation rating district and Craven place, due to a range of factors. This includes: facilitate health and care to become more joined up and coordinated 12 leadership challenges, failure to agree governance arrangements and future around people form and function, resulting in failure to achieve a viable form in time to reduce unwarranted variation in people’s experience of care receive delegated responsibilities from the Integrated Care System 3. ICP development framework - Led by Helen Hirst for WYH ICS Version 7 of the framework available and subject to the passage of the September 2021 legislation will be taken WY ICS for sign-off 4. Transition to ICS/P team to be established in response to the Work streams established and links with equivalent ICS work streams in place legislation (system group to support the creation and readiness of Complete the ICP) 5. Strategic Partnering Agreement update to reflect the new Work on the update will be overseen by the governance work stream October 2021 governance and partnership working arrangements 6. BdC risk management framework inc AF and RRs Governance work stream has collated each health and social care partners April 2022 strategic risk assurance framework into one document. 7. ICP system development plan to be established ICP system development plan, will concurrently through 2021/22 (work ongoing streams: (i) leadership & behaviours and (ii) communications & engagement) (will be monitored throughout via the ICP establishment programme board) 8. Lack detail on the organisational form at WY and BdC and on June 2021 System leaders have commenced conversations at both BdC and WYH readiness criteria to start, however deadline is to be ready Apr 22 footprints. A draft WY ICS operating model has been shared Assurance Mechanisms Assurance Details where / how do we get assurance that the existing controls are working effectively specific evidence of positive or negative assurances Internal: Checks and balances at system not currently built in part of the BD&C Strategic Partnering Agreement Governance (system committee structures) Section 75 agreement ICP Establishment Programme Board to establish progress reporting to Engagement with NHS, LA and VCS partners ICP Executive Board Governance structure including Wellbeing Boards, ICP Executive Board, System Finance and Performance Committee, System Quality Committee and Health and Care Partnership Boards Monthly System & Place (ICS and ICP) report to the CCG Senior Leadership Team Chief Officer's Report to Governing Body
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Strategic Risk Log – Risk 5.1 our Partnerships as the vehicle for enabling people to take more responsibility for their health and self care Risk Lead: Vicki Wallace (interim) / Nancy O’Neill Strategic Objective 5: Develop stronger collaborative partnerships in local places Strategic director of transformation and change deputy chief officer between the NHS, local government and others. Including a central role for primary care, Risk Owner: Vicki Wallace & Damien Kay, associate directors of collaborative provider arrangements and incorporate strategic commissioning through transformation and change systems with a focus on population health outcomes Supported by: James Drury, Programme Director Executive Board ICP establishment: There is a risk that we fail to gain sufficient Specific outcomes: Risk organisational traction towards Integrated Care Partnership for Bradford use population health management in areas experiencing high deprivation rating district and Craven place, due to a range of factors. This includes: facilitate health and care to become more joined up and coordinated 12 leadership challenges, failure to agree governance arrangements and future around people form and function, resulting in failure to achieve a viable form in time to reduce unwarranted variation in people’s experience of care receive delegated responsibilities from the Integrated Care System External System Oversight including quarterly Whole System Review Meetings held at place with NHSEI and WYH ICS with partners across BdC Bradford Wellbeing Board monitor progress against the metrics developed by LGA Minutes of Bradford Wellbeing Board Attendance at Overview and Scrutiny Committees Gaps in Assurance & Action Plan (where are we failing to gain evidence Implementation Progress to date that our controls are effective and how can we address this?) date 1. No equivalent system wide (at BdC) audit and governance Requirements of Governance structures has yet to be clarified, in the interim Committee we are establishing a chairs and elected members reference group to be TBC established to guide the ICP development with the aim of providing additional assurance for non-executives and elected members to be aware and support the changes in relation to ICP development 2. Reporting to ICP Exec Board to be established Shadow form to be in place by October 2021 which will include October 2021 reporting/governance processes Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register (number, brief description, current (CAF) in February 2021 score): 1.1 ICP Executive Board signed off approach to ICP Establishment on 30/04/21 Risk 1858: CCG fails to adequately discharge its responsibilities with regard to ICP Development Programme Board established and meetings commenced dis-establishment (16) ICP engagement sessions for lay members, NEDs, elected members (March 2021) Risk 1857: Risk to staff wellbeing, morale and motivation (12) due to impact of and AAO festival sessions for our people (May 2021) planned legislation ICP Establishment work streams are forming and will commence reporting into to Risk 1546: Member engagement in a larger CCG, impact of pandemic And ICP Development Programme Board from June 2021 ICS legislation (6) Lead for Design and Delivery element meeting regularly with work stream leads (fortnightly)
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Strategic Risk Log – Risk 6.1 our People a skilled, motivated workforce with a culture of continuous improvement Strategic Objective 6: We will continue to review and develop our internal resources, Risk lead: Liz Allen, strategic director of organisation effectiveness structures and processes to ensure that we are able to achieve our strategic objectives Risk owners: Fiona Jeffrey, associate director of organisation effectiveness as our commissioning functions transfer and, thereby, our CCG staff transition to new and Sue Baxter, strategic head of assurance Integrated Care System (ICS) and Integrated Care Partnership (ICP) arrangements. There is a risk of CCG staff struggling to adapt to revised system- and Specific outcomes: Risk partnership-focussed roles as we move towards the new ICS and ICP develop our inclusion and diversity as a team to better reflect and rating operating models by 1 April 2022 due to the need for different organisational understand our communities 12 forms and individual CCG staff role flexibility and the normal factors improve our skills and knowledge to increase our personal value associated with change, exacerbated by the impact of the Covid pandemic be responsible, holding ourselves and each other to account upon ways of working, resulting in failure to successfully transition our CCG staff. Risk Rating Rationale for current score: Score increased since January 2020 due to the (Likelihood x impact on ways of working (due to Covid) and legislative changes that will Impact) result in the transfer of CCG statutory functions to the ICS. CCG staff will transfer employment to the WY ICS though most are expected to continue to Initial 3 x 4 = 12 work at place (i.e. in the BDC ICP). (Sept 2017) Rationale for target score (risk appetite): Current 3 x 4 =12 As the impact of legislative change is clarified, and our plans to support staff (June 2021) are further developed, we aim to reduce the likelihood of staff not adapting to the transition. NHSE/I have committed to continue to employ all CCG staff Target 2 x4 = 8 below board level.
Partners / stakeholders involved: West Yorkshire ICS and Bradford district and Craven ICP stakeholders CCG managers and clinical leads CCG staff (including staff networks)
Existing controls Gaps in control where are we failing to put effective controls in place and what more what are the key controls in place to prevent this risk occurring? should be done to manage the risk CCG People Plan agreed by SLT and an action plan is in place Provision of equality, diversity and inclusion (EDI) specialist support is still Commissioning workforce development framework – our learning and development to be secured following the retirement of the CCG’s EDI lead at end of Feb (L&D) plan – aligns with our CCG People Plan and the NHS People Plan and was 2021 informed by a skills preference audit undertaken in summer 2020. This was An ICS transition transfer of functions task and finish group was initiated in launched in February 2021 and includes an expanded offer of blended learning and May 2021 but has still to agree and establish a common set of functions, development opportunities to all staff. related work streams and reporting arrangements with the five WY CCGs Workforce development group in place meets quarterly to oversee implementation and other stakeholders. Greater clarity is required as to the future A common process for L&D applications has been put in place operating model for the ICS in order to understand the potential impact on Page | 28
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Strategic Risk Log – Risk 6.1 our People a skilled, motivated workforce with a culture of continuous improvement Strategic Objective 6: We will continue to review and develop our internal resources, Risk lead: Liz Allen, strategic director of organisation effectiveness structures and processes to ensure that we are able to achieve our strategic objectives Risk owners: Fiona Jeffrey, associate director of organisation effectiveness as our commissioning functions transfer and, thereby, our CCG staff transition to new and Sue Baxter, strategic head of assurance Integrated Care System (ICS) and Integrated Care Partnership (ICP) arrangements. There is a risk of CCG staff struggling to adapt to revised system- and Specific outcomes: Risk partnership-focussed roles as we move towards the new ICS and ICP develop our inclusion and diversity as a team to better reflect and rating operating models by 1 April 2022 due to the need for different organisational understand our communities 12 forms and individual CCG staff role flexibility and the normal factors improve our skills and knowledge to increase our personal value associated with change, exacerbated by the impact of the Covid pandemic be responsible, holding ourselves and each other to account upon ways of working, resulting in failure to successfully transition our CCG staff. Bitesize learning and development offers are regularly provided all CCG staff. Human resources (HR) and L&D contract in place with BDCFT extended to 31 An ICP programme board was initiated in May 2021 but requires time and March 2022 (end of transition period). The service specification has been updated to resource to deliver against a broad range of work streams related to vision address priorities for the transition period and strategy, leadership and behaviour, design and delivery. Greater Documentation and guidance provided to line managers and staff to support clarity is required as to the future operating model for the ICP in order to effective annual appraisals, mid-year reviews and regular one-to-one conversations understand the potential impact on all CCG staff. (including personal and career development, flexible working and wellbeing) A CCG transition programme board will convene for the first time in June Support for on-line access to training is available 2021 and must be quickly established to ensure the safe and effective Workforce Race Equality Standard (WRES) action plan agreed by SLT and in place transfer of the CCG’s functions, people, assets and liabilities. Black, Asian and minority ethnic (BAME) and WellbeingandAble (WAA) staff The national HR framework has not yet been published by NHSE/I – this is networks in place, representatives attending SLT, bringing items on a monthly basis. required to provide guidance relevant to all our staff’s future employment. Both networks have governing body, strategic clinical director and associate director sponsors. Workforce equality plan (developed by the BAME and WAA staff networks) agreed by SLT and in place with senior staff identified to lead different elements New recruitment, selection and promotion policy developed in conjunction with BAME staff network, including a strengthened recruitment checklist mandated for use in all relevant processes Engagement sessions (mandatory for all managers) have taken place – focussed on new/revised recruitment, selection and promotion policy, flexible working procedures and home-based working policy (using case studies from staff’s lived experience) in order to ensure fair and consistent implementation and promote good practice Members of BAME network are invited to be involved throughout recruitment processes for senior (band 8a and above) posts, and other posts (where their capacity allows) CCG BAME staff taking part in the West Yorkshire ICS fellowship as mentors and mentees Page | 29
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Strategic Risk Log – Risk 6.1 our People a skilled, motivated workforce with a culture of continuous improvement Strategic Objective 6: We will continue to review and develop our internal resources, Risk lead: Liz Allen, strategic director of organisation effectiveness structures and processes to ensure that we are able to achieve our strategic objectives Risk owners: Fiona Jeffrey, associate director of organisation effectiveness as our commissioning functions transfer and, thereby, our CCG staff transition to new and Sue Baxter, strategic head of assurance Integrated Care System (ICS) and Integrated Care Partnership (ICP) arrangements. There is a risk of CCG staff struggling to adapt to revised system- and Specific outcomes: Risk partnership-focussed roles as we move towards the new ICS and ICP develop our inclusion and diversity as a team to better reflect and rating operating models by 1 April 2022 due to the need for different organisational understand our communities 12 forms and individual CCG staff role flexibility and the normal factors improve our skills and knowledge to increase our personal value associated with change, exacerbated by the impact of the Covid pandemic be responsible, holding ourselves and each other to account upon ways of working, resulting in failure to successfully transition our CCG staff. Wellbeing task and finish group formed with input from range of staff including network representatives have undertaken mapping and audit of total wellbeing offer to staff – including gap analysis. Controls action plan Implementation Progress to date what actions are being taken to address gaps in control? date 1. CCG resources to expand equality, diversity and inclusion Recurrent resource from the CCG corporate budget has been identified and specialist support for the CCG and system have been agreed will be provided to BTHFT who will recruit to a new (additional) 0.5 wte Band 7 and a specification is being finalised. This support should be August 2021 post. implemented for the CCG to the end of March 2022 and thereafter across the system. 2. CCG nominated lead (strategic director of organisation Weekly meetings have been set up for ICS, NHSE/I and CCG leads. The draft effectiveness) is attending the weekly WY ICS transition transfer terms of reference for our CCG transition programme board have been shared May 2021 to of functions task and finish group to work with system partners in along with the risk log from work undertaken when the three former CCGs March 2022 order to understand and respond to all requirements relevant to became one BDC CCG. the transfer of CCG statutory functions. 3. A number of CCG senior staff are taking lead roles and/or Regular meetings have been set up for place partners to begin to collaborate May 2021 to supporting the work streams set up to develop the operating within and across the various work streams. March 2022 model for the Bradford district and Craven ICP. 4. A new CCG transition programme board has been set up to Terms of reference have been drafted and members invited to monthly June 2021 to oversee, direct and manage the delivery of the CCG transition meetings starting June 2021. March 2022 during 2021/22 – with a particular emphasis on transfer of staff. 5. We are awaiting the publication of the national HR framework – The CCG accountable officer and senior HR business partner are closely due July 2021 involved with regional and system work to develop HR processes associated July 2021 to with the transfer of CCG statutory functions that, in turn, will impact our staff. March 2022
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Strategic Risk Log – Risk 6.1 our People a skilled, motivated workforce with a culture of continuous improvement Strategic Objective 6: We will continue to review and develop our internal resources, Risk lead: Liz Allen, strategic director of organisation effectiveness structures and processes to ensure that we are able to achieve our strategic objectives Risk owners: Fiona Jeffrey, associate director of organisation effectiveness as our commissioning functions transfer and, thereby, our CCG staff transition to new and Sue Baxter, strategic head of assurance Integrated Care System (ICS) and Integrated Care Partnership (ICP) arrangements. There is a risk of CCG staff struggling to adapt to revised system- and Specific outcomes: Risk partnership-focussed roles as we move towards the new ICS and ICP develop our inclusion and diversity as a team to better reflect and rating operating models by 1 April 2022 due to the need for different organisational understand our communities 12 forms and individual CCG staff role flexibility and the normal factors improve our skills and knowledge to increase our personal value associated with change, exacerbated by the impact of the Covid pandemic be responsible, holding ourselves and each other to account upon ways of working, resulting in failure to successfully transition our CCG staff. Assurance mechanisms Assurance details where / how do we get assurance that the existing controls are working effectively? specific evidence of positive or negative assurances Internal SLT and ALT members provide management, leadership and direction within and Our people have expressed positive feedback in relation to the monthly across the hubs and share issues, concerns, successes in CCG business and/or staff engagement sessions we are holding. development meetings Recent use of a particularly creative survey tool enabled staff to provide Workforce development group action plan reviewing progress every 3 months anonymous and candid responses as to their views about future working in 1:1 calls and development review meetings between managers and staff the ICS and ICP Workforce reporting to ALT including HR metrics Members of the WellbeingAndAble staff network met in April 2021 with the Annual workforce report to Governing Body strategic director of organisation effectiveness to share their negative Reporting against WRES action plan to ALT and SLT experiences of some interactions with the HR team in order for their EDI reporting in the CCG annual report concerns to be considered and addressed Feedback from staff networks to extended SLT (includes ALT members) External National NHS staff survey NHS staff survey results are still largely positive WRES national comparators Gaps in assurance and action plan where are we failing to gain Implementation Progress to date evidence that our controls are effective and how can we address this? date 1. CCG transition programme board (TPB) need to begin From In-place: CCG TPB commenced monthly meetings 08/06/2021 and plan first external and internal reporting – accountability and assurance July 2021 report to Governing Body in July.
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Strategic Risk Log – Risk 6.1 our People a skilled, motivated workforce with a culture of continuous improvement Strategic Objective 6: We will continue to review and develop our internal resources, Risk lead: Liz Allen, strategic director of organisation effectiveness structures and processes to ensure that we are able to achieve our strategic objectives Risk owners: Fiona Jeffrey, associate director of organisation effectiveness as our commissioning functions transfer and, thereby, our CCG staff transition to new and Sue Baxter, strategic head of assurance Integrated Care System (ICS) and Integrated Care Partnership (ICP) arrangements. There is a risk of CCG staff struggling to adapt to revised system- and Specific outcomes: Risk partnership-focussed roles as we move towards the new ICS and ICP develop our inclusion and diversity as a team to better reflect and rating operating models by 1 April 2022 due to the need for different organisational understand our communities 12 forms and individual CCG staff role flexibility and the normal factors improve our skills and knowledge to increase our personal value associated with change, exacerbated by the impact of the Covid pandemic be responsible, holding ourselves and each other to account upon ways of working, resulting in failure to successfully transition our CCG staff. Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register number, brief description, current score (CAF) in February 2021 1.1 Significant progress has been made in the implementation of plans related to our people, *New risk 1857 risk to staff wellbeing, morale and motivation due to workforce development, the workforce race equality standard, workforce equality actions transfer of commissioning functions, people, assets and liabilities to and staff wellbeing. New groups have been set up at ICS (West Yorkshire), ICP integrated care systems (12) (Bradford district and Craven) levels to manage the transition associated with planned *New risk 1858 risk that the CCG fails to adequately discharge its legislative changes to bring is new ICS and ICP operating models. responsibilities with regard to its own dissolution on 31 March 2022 (16)
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Strategic Risk Log – 7.1 our Leadership assuring the sustainability of our health and care system Strategic Objective 7: Working at Bradford district and Craven place, we will maximise Risk Lead: Robert Maden, Chief Finance Officer value for money in the use of healthcare services to ensure we can make shared Risk Owner: Diane Lawlor, Strategic Head of Finance for corporate reporting decisions on how to use our resources to improve population health. and financial control and Amy Paffett, Strategic Head of Finance for planning and transformation Risk There is a risk that we do not address the underlying financial deficit and Specific outcome: rating establish a financially sustainable position over the medium term as we exit make shared decisions on how to use our resources to improve population 16 the pandemic health Risk Rating Rationale for current score: (Likelihood x The financial regime around the pandemic has limited the CCG’s ability to Impact) improve the underlying financial deficient in 2020/21. Still need to understand the longer term impacts of COVID on services and also how the system will Initial 4 x 4 = 16 address the backlog of activity created. There is a major issue in relation to (Sept 2017) uncertainty going into the second half of the year (ie H1 and H2)
Current 4 x 4 =16 Management control in relation to Elective recovery fund (ERF) (June 2021) Rationale for target score (risk appetite): Target 2 x4 = 8 The impact of not closing the financial gap will always remain high but we want to lower the likelihood
Partners / stakeholders involved: Health and Care Partnership stakeholders Demand needs to be owned by all stakeholders in the footprint NHS England
Existing Controls Gaps in Control where are we failing to put effective controls in place and what more what are the key controls in place to prevent this risk occurring? should be done to manage the risk Joint planning process established across the Bradford place Waste reduction / savings programme not in place due to diversion of Business case process to support shared decision making on the use of resources resources to support the pandemic Expenditure controls in place to limit new expenditure commitments Prioritisation framework to support the use of resources to be finalised System transformation programmes established to support demand management Uncertainty over financial resources available in 2021/22 Bradford Place financial risk share arrangements Lack of understanding over local Place based approvals processes System Finance & Performance Committee established Fixed income contracts with main local providers implemented from 2019/20. Demand management initiatives (e.g. GP streaming, pathway adherence, evidence based interventions, etc.)
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Strategic Risk Log – 7.1 our Leadership assuring the sustainability of our health and care system Strategic Objective 7: Working at Bradford district and Craven place, we will maximise Risk Lead: Robert Maden, Chief Finance Officer value for money in the use of healthcare services to ensure we can make shared Risk Owner: Diane Lawlor, Strategic Head of Finance for corporate reporting decisions on how to use our resources to improve population health. and financial control and Amy Paffett, Strategic Head of Finance for planning and transformation Risk There is a risk that we do not address the underlying financial deficit and Specific outcome: rating establish a financially sustainable position over the medium term as we exit make shared decisions on how to use our resources to improve population 16 the pandemic health Controls Action Plan (what actions are being taken to address gaps in Implementation Progress to date control) date 1. Establish underlying financial position and H1 expenditure runs Local H1 expenditure runs rates has been carried out across West Yorkshire. rates to inform resource requirement for H2 2021/22 August 2021 Stage 1 in May to inform NHSEI meeting
2. Model expenditure forecasts for Q2 to Q4 2021/22 based on 2 Expenditure profile for release of monies 2022/23 onwards. scenarios; return to business as usual trajectories December 2021 the capacity and resource required to address the backlog of activity 3. Utilise prioritisation framework to clarify investment priorities and Finalised / final draft Prioritisation framework is currently being designed. cost pressures for inclusion in the 2021/22 plan May 21 / June Expect a draft version to be shared at next QIPP working group meeting in 2021 March. One system list being collated around all known cost pressures and requests for investment to ensure a systematic approach to prioritisation. To be presented to March System Finance and Performance Deputies meeting. 4. Scope efficiency opportunities and expected implementation Re-establishment of QIPP working group meeting including representatives timescales in light of impact of the pandemic; from System Transformation Programme. Remit of meeting to be agreed but June 2021 expectation is that this will oversee the efficiency programme of work. QIPP opportunities starting to be listed e.g. Medicines Optimisation Group work, continuing care (National Framework criteria) 5. Confirm local Place based business case approvals processes June 2021 Checking the flow chart in the SPA Assurance Mechanisms (where / how do we get assurance that the existing controls are Assurance Details (specific evidence of positive or negative assurances) working effectively) Internal Link to NHS Oversight Framework indicator 141a (in-year financial Involvement of SLT and Governing Body members in development of plans performance) Q4 19/20 – BC rated AMBER, with AWC and BDs rated RED Sign-off of plans by F&P Committee and Governing Body Monthly non-ISFE submission to NHSE on year to date and forecast Monthly financial reporting to SLT, CCG F&P, System F&P and Bradford Place financial position Forums and Health and Care Executive Board Annual accounts submission Reporting to Finance and Performance Committee, SLT, Governing Body External audit opinion
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Strategic Risk Log – 7.1 our Leadership assuring the sustainability of our health and care system Strategic Objective 7: Working at Bradford district and Craven place, we will maximise Risk Lead: Robert Maden, Chief Finance Officer value for money in the use of healthcare services to ensure we can make shared Risk Owner: Diane Lawlor, Strategic Head of Finance for corporate reporting decisions on how to use our resources to improve population health. and financial control and Amy Paffett, Strategic Head of Finance for planning and transformation Risk There is a risk that we do not address the underlying financial deficit and Specific outcome: rating establish a financially sustainable position over the medium term as we exit make shared decisions on how to use our resources to improve population 16 the pandemic health External Financial Plan sign off by NHSE&I Collaborative agreement of plans by the WY&H ICS Reporting to System Finance & Performance Committee, Health and Care Partnership Boards and West Yorkshire & Harrogate ICS Role of NHS England/Improvement as regulators Act as One system programme boards and WYH ICS 10 ambitions Gaps in Assurance & Action Plan (where are we failing to gain Implementation Progress to date evidence that our controls are effective and how can we address this?) date No gaps in assurance currently. Not applicable Not applicable Key changes since the last review of this commissioning assurance framework Related risks on the Risk Register number, brief description, current score (CAF) in February 2021 1.1 Development of system-wide savings schemes. Risk 1862: Financial arrangements for H1 2021/22 (16) Nationally mandated block contracts with Trusts and the removal of non-contracted Risk 1694: Underlying financial position risk (16) activity charges Risk 1549: Loss of local financial control (10) Development of system wide prioritisation matrix for investments
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NHS Bradford District and Craven CCG This document provides a summary and/or key discussion points and recommendations relevant to the subject of an item for consideration at the specified CCG meeting for the purpose of assurance, information, decision or action.
Agenda item 12
Name of meeting Governing Body Meeting date 13 July 2021 Sue Baxter, Strategic Head Title of report Minor changes to the CCG Report author(s) of Assurance & Diane Constitution Lawlor, Strategic Head of Finance Liz Allen, Strategic Director – Organisation Effectiveness, & Lead(s) / SRO Report lead(s) Sue Baxter & Diane Lawlor Robert Maden, Chief Finance Officer Supporting Date meeting Audit & Governance Committee 5 July 2021
Paper summary and/or key discussion points Following internal audits of our governance framework, minor and moderate changes were recommended when the CCG’s Constitution was next reviewed. These recommended changes are to strengthen clarity on where functions of the Governing Body have been delegated to, as recommended by internal auditors. All changes made to the CCG constitution are marked by track changes.
Under the current constitution, the Governing Body (rather than CCG members) may approve proposed amendments to the constitution unless: changes are thought to have a material impact. changes are proposed to the reserved powers of the members or the role and appointment of member practice representatives (including the GP members of the clinical executive). at least half (50%) of all the Governing Body Members formally request that the amendments be put before the membership for approval.
Changes are set out below, and are minor points of clarification and therefore not material changes. The areas for change are as a result of the following:
internal auditor recommendations from the governance framework audit report and from the Individual Funding Request audit report updates to the Terms of Reference carried out during the committee effectiveness review earlier this year. changes to roll-over tenure due to the dissolution of the CCG on the 31 March 2022
Internal audit reports:
Following the recommendations made by Internal Auditors a small number of amendments are considered operationally necessary to the CCG Constitution, Scheme of Reservation & Delegation and the Financial Scheme of Delegation (these are shown as track changes on the attached document).
Terms of reference:
Changes to Terms of Reference have been considered as part of the annual committee effectiveness review undertaken in February and March, there include changes to the senior leadership team, which were approved by the CCG council on 24 March 2021.
1 213 214 Tenure roll-over:
Andrew Morgan’s (Head of Planning and Regulation – North East & Yorkshire), letter dated 1 March 2021, stated “For CCGs in North East & Yorkshire, where the tenure of positions within the Governing Body and of lay members will end in March 2021. CCG leads, supported by the ICS leads, will be able to roll over the tenure of these posts for a further 12 months while holding any vacancies where it does not create any risk to the governance of the CCG. However, given the current pressures as a result of the COVID pandemic response and the extensive process for CCGs to undertake to make constitutional changes, the most pragmatic response is not to require CCGs to make changes to their constitutions during this time.” Within the CCG Constitution under 2.2.2 related to the term of office bullet d) has been added “where the tenure of positions within the Governing Body and of lay members was due to end in March 2021 we have rolled over the tenure of these posts for a further 12 months to March 2022.”
It is considered appropriate that the Governing Body be requested to approve the minor constitutional amendments, these changes will not require CCG council approval, nor NHSEI approval. Outline how this will help us to achieve our vision through our strategic ambitions: Our population – improving health and equity for local people, and/or Our partnerships – as the vehicle for enabling people to take more responsibility for their health, and/or Our people – a skilled, motivated workforce with a culture of continuous improvement, and/or Our leadership – assuring sustainability of our health and care system.
Our leadership The CCG Constitution and associated documents describe the governing principles, rules and procedures that the clinical commissioning group will establish to provide probity and accountability in the day-to-day running of the clinical commissioning group.
Purpose assurance information decision action
approve / recommend / review / consider / support / ratify comment / discuss Recommendation(s)
The Governing Body is asked to: 1. approve the minor (non-material) changes to the CCG constitution, Scheme of Reservation & Delegation and Financial Scheme of Delegation 2. note that due to the changes not being material the CCG constitution does not require an approval process via CCG Council or NHSEI
Appendices (or other supporting papers)
1. Internal Audit recommendations - detailed 2. CCG Constitution a. Terms of reference (Appendix 2 of the constitution) b. Standing Orders (Appendix 3 of the constitution) 3. Scheme of Reservation and Delegation 4. Financial Scheme of Delegation
2 214 215 Appendix 1: Internal Audit recommendations
1. Governance framework audit report
The Governance Framework Internal Audit Report in published on the 28 January 2021, gave an overall opinion of significant assurance highlighting a small number of minor priority recommendations. In relation to the CCG constitution the auditors stated “The previous model constitution more clearly identified where the responsibility for securing the discharge of functions and statutory duties was delegated to in the CCG. This section has been removed from the new model constitution. There is scope for strengthening clarity in the new governance documents as to where responsibilities for the discharge of these previously specified functions sit.” And “With the exception of some queries highlighted in Appendix A it has been confirmed that the decision making authorities of each governance forum is clearly and consistently specified”.
The following recommendations where made (not material changes):
Recommendation Priority
1. When next reviewing the Constitution removed reference to the Prime Financial Policies Minor 2. Finalise and approve the terms of reference for the Finance and Performance Committee Minor 3. Update the terms of reference for the Quality Committee to replace reference to the Clinical Minor Boards 4. Insert the full delegation agreement in the terms of reference for the Primary Care Minor Commissioning Committee when next reviewed and updated 5. For the specified functions and duties review and confirm where these have passed to in the new governance structure. Seek approval for the shift in any delegation from the Moderate Governing Body 7. If it confirmed that these duties and functions have been delegated to the SLT include a statement in the SLT terms of reference to the effect that strategies and supporting processes Minor are developed to support the achievement of the CCG’s statutory functions on behalf of the CCG 12. Review notes* and agree and action changes to the governance documents when they are Moderate next due for update
Notes* for recommendation 12 - minor changes to the CCG constitution the SORD and the Standing Orders
In paragraph 5.4.1 of the Constitution it states ‘The Governing Body has statutory responsibility for ‘ensuring that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the CCG’s principles of good governance..’ It is stated in the SoRD that the Governing Body has responsibility for the ‘Approval of the arrangements for discharging the group’s statutory financial duties. The broader statutory role re effectively, efficiently and economically is not reflected. In paragraph 5.4.2 of the Constitution its states ‘The CCG has also delegated the following additional functions to the Governing Body which are also set out in the Scheme of Reservation and Delegation (SoRD)’. Not all the functions are referenced in the SoRD. As the functions described are not authorities it may be more appropriate to remove reference to the SoRD in this paragraph. In the Constitution (5.9.9) and the SoRD it states that the Council of Members has authority to ‘Approve the process for the selection and appointment of the non-elected members of the governing body.’ This is not reflected in its terms of reference. It also states in paragraph 5.9.9 in the Constitution and in the SoRD that the Council of Members ‘Receive the CCG’s annual report and annual accounts.’ This is not reflected in its terms of reference. There is a slight difference in wording between the Constitution (5.10.2) and the SoRD with reference to the Remuneration Committee. The latter refers to making recommendations re redundancy payments whereas the former does not. The terms of Reference reflect the Constitution. Paragraphs 5.12.2, 5.13.2 and 5.14.2 relate to the approval of any arrangements for joint commissioning. This approval rests with SLT where not delegated to the Governing Body. Following further discussion with the Head of Corporate Governance the latter would approve frameworks for joint commissioning as opposed to the commissioning plans themselves. This is not explicitly defined in the Constitution, SoRD or terms of reference for SLT but the logic can be traced. As the CCG develops and joint commissioning evolves this delegation should be kept under review for clarity. [Note removal of governing body] 3 215 216 Is this not clear in the ‘Partnership Working’ section of the SORD and para 5.11.2 of the constitution? In the Standing Orders and the terms of reference for the Council it refers to them approving the process for appointment of the Accountable Officer. In the SoRD it states that the Council of Members will ‘Recommend the appointment of the accountable officer to NHS.’ [Note reference to recommendation is removed] In the Standing Orders its states that the appointment process for the Clinical Chair will be determined by the Chief Officer and approved by the CCG Council. This authority is not reflected in the SoRD or terms of reference for the Council. In the SoRD it states that the Council of Members will undertake ‘Referral of employee members of the governing body or senior leadership team for management under the CCG’s HR policies and procedures, via a 75% majority vote of confidence at a meeting of the council of members.’ In the terms of reference for the Council of Member sit states 50%. The Standing Orders agrees to the SoRD. In the SoRD it states that the Audit and Governance Committee will ‘Approve the timetable for the preparation and approval of the group’s annual report and annual accounts’. This is not reflected in the Committee’s terms of reference.’ In effect the Committee receives assurance on the timetable rather than approving it. [Note removed from the SoRD]. In the terms of reference for the Remuneration Committee it states that it will ‘Approve the disciplinary policy and procedure for the CCG’. In the SoRD it refers to SLT approving HR policies. This is the case with the exception of the disciplinary policy. The distinction should be clarified in the SORD. In the terms of reference for the Finance and Performance Committee and the SoRD it states that it has the authority to ‘Approve arrangements for risk sharing and / or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006).’ In the SoRD it states that this could also be SLT or the Governing Body. [Note: removed or SLT or GB] In paragraph 2.2.8 of the Standing Orders the following statements contradict each other: a) Nominations – not applicable; the Deputy Clinical Chair shall be selected by the Clinical Chair from one of the Lay Members. b) Eligibility – only GP members of the Senior Leadership Team are eligible to act as Deputy Clinical Chair. This error is also repeated in the Constitution under the definitions section. It is correct in the SoRD. In the SoRD it states that the Governing Body undertakes ‘Approval of variations to the approved budget where variation would have a significant impact on the overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims.’ In the detailed scheme of delegation it refers to virements above £50k being approved by the Chief Finance Officer/Chief Officer. There is no reference to what is significant beyond £50k to be referred back to the Governing Body. In the SoRD it states that SLT has responsibility for the ‘Approval of the group’s business continuity plan.’ It also states that the Governing Body will ‘Approve the group’s arrangements for business continuity and emergency planning’. This is a potential overlap in authority. In the SoRD it states that the Governing Body GB will ‘Approve proposals for action on litigation against or on behalf of the clinical commissioning group.’ It should be clarified whether this is correct or whether this authority sits with the Accountable Officer. In the SoRD it states that the Governing Body will ‘Approve the group’s arrangements for handling complaints’. It should be clarified whether this is correct or whether this authority sits with the Quality Committee. In the Finance Scheme of Delegation it states that the Chief Finance Officer is responsible for ‘Maintenance and operation in accordance with mandate approved by the Governing Body.’ No reference to the Governing Body approving the bank mandate has been evidenced in the key documentation.
2. Individual funding request audit report
Minor change recommended to the Financial Scheme of Delegation
In addition to the internal audit of the CCG’s Governance Framework, we also had an internal audit of the CCG’s Individual Funding Requests issued on the 15 February 2021. With a recommendation of a minor change to the Financial Scheme of Delegation
Recommendation Priority
The IFR Policy and Procedure and the Financial Scheme of Delegation should be reviewed Minor and amended to show the delegated authority for approval of IFRs.
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NHS Bradford District and Craven CLINICAL COMMISSIONING GROUP
CONSTITUTION
217 218 NHS Bradford District and Craven Clinical Commissioning Group Constitution
Version Author Description Circulation and Date V1.0 Sarah Dick, Version approved by members (27th February CCG wide, website. March Head of 2020) and NHS England (9th March 2020). 2020 Corporate Governance V1.1 May As above Review and update: Governing Body 13 July 2021 - minor amendments recommended by 2021 Internal Audit - - refresh of Terms of Reference (no CCG wide, website material changes)
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CONTENTS
1 Introduction ...... 5 1.1 Name ...... 5 1.2 Statutory Framework ...... 5 1.3 Status of this Constitution ...... 6 1.4 Amendment and Variation of this Constitution ...... 6 1.5 Related documents ...... 7 1.6 Accountability and transparency ...... 7 1.7 Liability and Indemnity ...... 8
2 Area Covered by the CCG ...... 9
3 Membership Matters ...... 11 3.1 Membership of the Clinical Commissioning Group ...... 11 3.2 Nature of Membership and Relationship with CCG ...... 17 3.3 Speaking, Writing or Acting in the Name of the CCG ...... 17 3.4 Members’ Rights ...... 17 3.5 Members’ Meetings ...... 17 3.6 Practice Representatives ...... 17
4 Arrangements for the Exercise of our Functions ...... 19 4.1 Good Governance ...... 19 4.2 General ...... 19 4.3 Authority to Act: the CCG ...... 20 4.4 Authority to Act: the Governing Body ...... 20
5 Procedures for Making Decisions ...... 21 5.1 Scheme of Reservation and Delegation ...... 21 5.2 Standing Orders ...... 21 5.3 Standing Financial Instructions (SFIs) ...... 22 5.4 The Governing Body: Its Role and Functions ...... 22 5.5 Composition of the Governing Body ...... 23 5.6 Additional Attendees at Governing Body Meetings ...... 24 5.7 Appointments to the Governing Body ...... 24 5.8 Committees and Sub-Committees ...... 24 5.10 Committees of the Governing Body ...... 27 5.11 Collaborative Commissioning Arrangements ...... 28
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5.12 Joint Commissioning Arrangements with Local Authority Partners ...... 29 5.13 Joint Commissioning Arrangements – Other CCGs ...... 31 5.14 Joint Commissioning Arrangements with NHS England...... 32
6 Provisions for Conflict of Interest Management and Standards of Business Conduct ...... 35 6.1 Conflicts of Interest...... 35 6.2 Declaring and Registering Interests...... 35 6.3 Training in Relation to Conflicts of Interest ...... 36 6.4 Standards of Business Conduct ...... 36
Appendix 2: Committee Terms of Reference ...... 42
Appendix 3: Standing Orders ...... 87
Appendix 4: Financial Scheme of Delegation ...... 107
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1 Introduction
1.1 Name
The name of this clinical commissioning group is NHS Bradford District and Craven Clinical Commissioning Group (“the CCG”).
1.2 Statutory Framework
1.2.1 CCGs are established under the NHS Act 2006 (“the 2006 Act”), as amended by the Health and Social Care Act 2012. The CCG is a statutory body with the function of commissioning health services in England and is treated as an NHS body for the purposes of the 2006 Act. The powers and duties of the CCG to commission certain health services are set out in sections 3 and 3A of the 2006 Act. These provisions are supplemented by other statutory powers and duties that apply to CCGs, as well as by regulations and directions (including, but not limited to, those issued under the 2006 Act).
1.2.2 When exercising its commissioning role, the CCG must act in a way that is consistent with its statutory functions. Many of these statutory functions are set out in the 2006 Act but there are also other specific pieces of legislation that apply to CCGs, including the Equality Act 2010 and the Children Acts. Some of the statutory functions that apply to CCGs take the form of statutory duties, which the CCG must comply with when exercising its functions. These duties include things like:
a) Acting in a way that promotes the NHS Constitution (section 14P of the 2006 Act); b) Exercising its functions effectively, efficiently and economically (section 14Q of the 2006 Act); c) Financial duties (under sections 223G-K of the 2006 Act); d) Child safeguarding (under the Children Acts 2004,1989); e) Equality, including the public-sector equality duty (under the Equality Act 2010); and f) Information law, (for instance under data protection laws, such as the EU General Data Protection Regulation 2016/679, and the Freedom of Information Act 2000).
1.2.3 Our status as a CCG is determined by NHS England. All CCGs are required to have a constitution and to publish it.
1.2.4 The CCG is subject to an annual assessment of its performance by NHS England which has powers to provide support or to intervene where it is satisfied that a CCG is failing, or has failed, to discharge any of its functions or that there is a significant risk that it will fail to do so.
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1.2.5 CCGs are clinically-led membership organisations made up of general practices. The members of the CCG are responsible for determining the governing arrangements for the CCG, including arrangements for clinical leadership, which are set out in this Constitution.
1.3 Status of this Constitution
1.3.1 This CCG was first authorised on 9th March 2020.
1.3.2 Changes to this constitution are effective from the date of approval by NHS England.
1.3.3 The constitution is published on the CCG website at www.bradfordcravenccg.nhs.uk
1.4 Amendment and Variation of this Constitution
1.4.1 This constitution can only be varied in two circumstances.
a) where the CCG applies to NHS England and that application is granted; and or b) where, in the circumstances set out in legislation, NHS England varies the constitution other than on application by the CCG.
1.4.2 The CCG Council, which comprises representatives from CCG member practices, is responsible for approving any proposed amendments to this constitution before the CCG applies to NHS England for constitutional amendment, subject to paragraph 1.4.4.
1.4.3 Proposed amendments to the constitution will also be shared with the Local Medical Committee, prior to submission to the CCG Council for approval.
1.4.4 The Accountable Officer (known within the CCG as the ‘Chief Officer’) may periodically propose amendments to the constitution which shall be considered and approved by the Governing Body unless:
Changes are required for legal reasons; Changes are thought to have a material impact; Changes are proposed to the reserved powers of the members or the role and appointment of GP members of the Senior Leadership Team); At least half (50%) of all the Governing Body members formally request that the amendments be put before the membership for approval
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1.5 Related documents
1.5.1 This Constitution is also informed by a number of documents which provide further details on how the CCG will operate. They are the CCG’s:
a) Standing Orders – which set out the arrangements for meetings and the selection and appointment processes for the CCG’s Committees, and the CCG Governing Body (including Committees). b) The Scheme of Reservation and Delegation – sets out those decisions that are reserved for the membership as a whole and those decisions that have been delegated by the CCG or the Governing Body. c) Standing Financial Instructions – which set out the delegated limits for financial commitments on behalf of the CCG. d) Conflicts of Interest and Standards of Business Conduct Policy – which includes the arrangements the CCG has made for the management of conflicts of interest. e) Committee terms of reference.
The documents above can be found here: www.bradfordcravenccg.nhs.uk
With the exception of the terms of reference included within Appendix 2 of this constitution, Standing Orders (Appendix 3) and the Financial Scheme of Delegation (Appendix 4), the documents listed above do not form part of the CCG constitution for the purposes of 1.4 above.
1.6 Accountability and transparency
1.6.1 The CCG will demonstrate its accountability to its members, local people, stakeholders and NHS England in a number of ways, including by being transparent. We will meet our statutory requirements to:
a) publish our constitution and other key documents as set out in Section 1.5.1; b) appoint independent lay members and non-GP clinicians to our Governing Body; c) manage actual or potential conflicts of interest in line with NHS England’s statutory guidance Managing Conflicts of Interest: Revised Statutory Guidance for CCGs 2017 and expected standards of good practice (see also part 6 of this constitution); d) hold Governing Body meetings in public (except where we believe that this would not be in the public interest); e) publish an annual commissioning strategy that takes account of priorities in the health and wellbeing strategy; f) procure services in a manner that is open, transparent, non- discriminatory and fair to all potential providers and publish a Procurement Strategy;
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g) involve the public, in accordance with its duties under section 14Z2 of the 2006 Act, and as set out in more detail in the CCG’s website; www.bradfordcravenccg.nhs.uk h) when discharging its duties under section 14Z2, the CCG will ensure that it discharges this function in accordance with the principles set out in patient and public participation in the commissioning of health and care: statutory guidance for CCGs and NHS England; i) comply with local authority health overview and scrutiny requirements; j) meet annually in public to present the CCG annual report which is then published; k) produce annual accounts which are externally audited; l) publish a clear complaints process; m) comply with the Freedom of Information Act 2000 and with Information Commissioner Office requirements regarding the publication of information relating to the CCG; n) provide information to NHS England as required; and o) be an active member of the local Health and Wellbeing Board.
1.7 Liability and Indemnity
1.7.1 The CCG is a body corporate established and existing under the 2006 Act. All financial or legal liability for decisions or actions of the CCG resides with the CCG as a public statutory body and not with its member practices.
1.7.2 No member or former member, nor any person who is at any time a proprietor, officer or employee of any member or former member, shall be liable (whether as a member or as an individual) for the debts, liabilities, acts or omissions, howsoever caused by the CCG in discharging its statutory functions.
1.7.3 No member or former member, nor any person who is at any time a proprietor, officer or employee of any member or former member, shall be liable on any winding-up or dissolution of the CCG to contribute to the assets of the CCG, whether for the payment of its debts and liabilities or the expenses of its winding-up or otherwise.
1.7.4 The CCG may indemnify any member practice representative or other officer or individual exercising powers or duties on behalf of the CCG in respect of any civil liability incurred in the exercise of the CCG’s business, provided that the person indemnified shall not have acted recklessly or with gross negligence.
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2 Area Covered by the CCG
2.1 The geographical area covered by NHS Bradford District and Craven Clinical Commissioning Group is outlined below and covers 71 practices (as at 1st April 2020).
2.2 The CCG covers the entire area of the City of Bradford Metropolitan District Council, made up of following Lower-layer Super Output Areas1:
E01010638 to E01010648 E01010691 to E01010729 E01010767 to E01010774 E01010854 to E01010863 E01010599 E01010606 to E01010609 E01010611 E01010613 E01010617 E01010621 to E01010622 E01010624 E01010676 E01010679 E01010730 to E01010734 E01010736 to E01010738 E01010792 to E01010793 E01010812 to E01010813 E01010823 to E01010824 E01010828 to E01010834 E01010836 E01010838 to E01010839 E01010841 to E01010844 E01010568 to E01010598 E01010600 to E01010605 E01010610 E01010612 E01010614 to E01010616 E01010618 to E01010620 E01010623 E01010625 to E01010637 E01010649 to E01010675 E01010677 to E01010678
1 Lower Layer Super Output Areas (LSOAs) describe the geographic area of the CCG for reporting purposes. LSOAs are part of a geographic hierarchy designed to improve the reporting of small area statistics in England and Wales and align to post-codes.
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E01010680 to E01010690 E01010735 E01010739 to E01010766 E01010775 to E01010791 E01010794 to E01010811 E01010814 to E01010822 E01010825 to E01010827 E01010835 E01010837 E01010840 E01010845 to E01010853 E01010864 to E01010874
2.3 In the North Yorkshire County Council area of Craven, the CCG covers the following Lower-layer Super Output Areas:
E01027555 to E01027557 E01027560 to E01027569 E01027571 to E01027586
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3 Membership Matters
3.1 Membership of the Clinical Commissioning Group
3.1.1 The CCG is a membership organisation.
3.1.2 All practices who provide primary medical services to a registered list of patients under a General Medical Services, Personal Medical Services or Alternative Provider Medical Services contract in our area are eligible for membership of this CCG.
3.1.3 The practices which make up the membership of the CCG are listed below:
Practice Name Address
Addingham Medical Centre 151a Main Street, Addingham, Ilkley, West Yorkshire, LS29 0LZ Ashcroft Surgery Newlands Way, Eccleshill, Bradford BD10 0JE Ashwell Medical Centre Ashwell Road, Manningham, Bradford BD8 9DP Avicenna Medical Practice The Bluebell Building, Barkerend Health Centre, BD3 8QH Baildon Medical Practice 10 Newton Way, Baildon BD17 5NH Bevan Healthcare 14 Piccadilly BD1 3LS Bilton Medical Centre 120 City Road, BD8 8JT Bingley Medical Practice Canalside Health Centre, 2 Kingsway, Bingley BD16 4RP Bowling Highfield Medical Rooley Lane, Bradford BD4 7SS Practice Highfield Health Centre, 2 Proctor Street, Off Tong Street, Bradford BD4 9QA The Bradford Moor Practice The Bluebell Building, Barkerend Health Centre, BD3 8QH Bradford Student Health University Of Bradford, Halls of Service Residence, Laisteridge Lane, BD5 0NH The City Medical Practice Whetley Medical Centre, 2 Saplin Street, BD8 9DW Clarendon Medical Centre Alice Street, Off Lumb Lane, BD8 7RT Manningham Health Centre, Lumb Lane, BD8 7SY
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Practice Name Address
Cowgill Surgery (Affinity Thornaby Drive, Clayton, Bradford Care) BD14 6ES Cross Hills Group Practice Holme Lane, Cross Hills (Modality Partnership) North Yorkshire, BD20 7LG Dr Akbar The Bluebell Building, Barkerend Health Centre, BD3 8QH Hillside Bridge Health Care Centre, 4 Butler Street, BD3 0BS Dyneley House Surgery Newmarket Street, Skipton, North Yorkshire, BD23 2HZ Eccleshill Village Surgery 14 Institute Road, Bradford BD2 2HX
Farfield Group Practice St Andrews Surgeries, West Lane (Modality Partnership) Keighley , West Yorkshire, BD21 2LD The Family Practice Whetley Medical Centre, 2 Saplin Street, BD8 9DW Farrow Medical Centre 177 Otley Road, Bradford, BD3 0HX Fisher Medical Centre Millfields, Coach Street, (Modality Partnership) Skipton, North Yorkshire, BD23 1EU Frizinghall Medical Centre 274 Keighley Road, Frizinghall, BD9 4LH Grange Medical Centre 1 Horton Grange Road, Bradford, BD7 3AH Grange Park Surgery Grange Road, Burley-in-Wharfedale Ilkley, West Yorkshire, LS29 7HG Haigh Hall Medical Centre Haigh Hall Road, Greengates, Bradford (Affinity Care) BD10 9AZ Haworth Medical Practice Heathcliffe Mews, Haworth, (Modality Partnership) Keighley, West Yorkshire, BD22 8DH Hollyns Health and Wellbeing Allerton Health Centre, Bell Dene Road, Allerton, Bradford BD15 7NJ Hollyns Health and Wellbeing, 4 Glenholme Park, Pasture Lane, Clayton, Bradford BD14 6NF Holycroft Surgery (Modality The Health Centre, Oakworth Road, Partnership) Keighley, West Yorkshire, BD21 1SA Horton Bank Top Practice 1220 Great Horton Road, Bradford, BD7 4PL
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Practice Name Address
Horton Park Surgery Horton Park Surgery, 99 Horton Park Avenue, Bradford BD7 3EG 2 Brompton Road, Bradford, BD4 7JD Idle Medical Centre 440 Highfield Road, Idle, Bradford BD10 8RU Ilkley and Wharfedale Springs Medical Centre, Springs Lane, Medical Practice Ilkley, West Yorkshire, LS29 8TQ Ilkley Moor and Grassington Springs Medical Centre, Springs Lane, Medical Practice Ilkley, West Yorkshire, LS29 8TH 9 Station Road, Grassington, North Yorkshire, BD23 5LS Kensington Partnership Kensington Street Health Centre, Whitefield Place, Girlington, BD8 9LB Lower Grange Medical Centre, The Square, Charteris Road, Bradford BD8 0QN Mughal Medical Centre, 55 Ivanhoe Road, Bradford BD7 3HY Woodroyd Centre, Woodroyd Road, Off Greenway Road, Bradford BD5 8EL Kensington Street Heath Kensington Street Health Centre, Centre – Dr Gilkar Whitefield Place, Girlington, BD8 9LB Kilmeny Group Medical 50 Ashbourne Road, Ingrow. Practice (Modality Keighley, West Yorkshire, BD21 1LA Partnership)
Leylands Medical Practice 81 Leylands Lane, Heaton, Bradford BD9 5PZ Kings Road, Wrose, BD2 1QG
Haworth Road, Bradford BD9 6LL Ling House Medical Centre 49 Scott Street, Keighley, West Yorkshire, BD21 2JH Little Horton Lane Medical 392 Little Horton Lane, BD5 0NX Centre - Dr Gilkar
Little Horton Lane Medical 392 Little Horton Lane, BD5 0NX Centre - Dr Raja & Partners
Lister Surgery Westbourne Green CHC Centre, 50 Heaton Road, BD8 8RA
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Practice Name Address
Low Moor Medical Centre 29 The Plantations, Low Moor, Bradford BD12 0TH Manor Medical Practice Girlington Health Centre, 195 Girlington Road, Girlington, Bradford BD8 9PB Allerton Health Centre, Bell Dene Road, Allerton, Bradford BD15 7NJ Moor Park Medical Practice The Bluebell Building, Barkerend Health Centre, BD3 8QH Moorside Surgery 370 Dudley Hill Road, Bradford BD2 3AA Oak Glen Surgery Eldwick and Gilstead Health Centre, 196 Swan Avenue, Bingley BD16 3PA Oakworth Medical Practice 3 Lidget Mill, Oakworth, (Modality Partnership) Keighley, West Yorkshire, BD22 7HY Park Grange Medical Centre 141 Woodhead Road, BD7 2BL Parklands Medical Practice 30 Buttershaw Lane, Bradford BD6 2DD Park Road Surgery, Park Road, Off Manchester Road, Bradford BD5 0SG Parkside Medical Practice Horton Park Centre, 99 Horton Park Ave, BD7 3EG Peel Park Surgery Undercliffe Health Care Centre, 17 Lowther Street, BD2 4RA Picton Medical Centre Westbourne Green CHC Centre, 50 Heaton Road, BD8 8RA Whetley Medical Centre, 2 Saplin Street, BD8 9DW Primrose Surgery Hillside Bridge Health Care Centre, 4 Butler Street, BD3 0BS North Street Surgery (Affinity 151 North Street, Keighley, Care) West Yorkshire, BD21 3AU The Ridge Medical Practice The Ridge Medical Centre, Cousen Road, Bradford BD7 3JX The Ridge Medical Centre, 93 Smith Avenue, Bradford BD6 1HA
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Practice Name Address
Royds Healthy Living Centre, 20 Ridings Way, Off The Crescent, Buttershaw, Bradford, BD6 3UD Rockwell & Wrose Medical Kings Road, Bradford BD2 1QG Practice Rockwell Medical Centre, Thorpe Edge, Bradford BD10 8DP Rooley Lane Medical Rooley Lane, Bradford BD4 7SS Practice
Saltaire and Windhill Medical Richmond Road, Shipley BD18 4RX Partnership Canon Pinnington Mews, Cottingley, BD16 1 AQ 2 Thackley Old Road, Shipley BD18 1QB Baildon Cliff Avenue Surgery, Shipley BD17 6NX Shipley Medical Centre Shipley Health Centre, Alexandra Road, (Affinity Care) Shipley BD18 3EG Westcliffe Road, Shipley BD18 3EE Silsden and Steeton Medical Elliott Street, Silsden, Practice (Modality Keighley, West Yorkshire, BD20 0DG Partnership) Chapel Road, Steeton, Keighley, West Yorkshire, BD20 6NU Springfield Medical Practice Canalside Healthcare Centre, 2 Kingsway, Bingley BD16 4RP Sunnybank Medical Practice Towngate, Wyke, Bradford BD12 9NG (Affinity Care)
Thornbury Medical Centre Rushton Avenue, Bradford, BD3 7HZ Thornton and Denholme Thornton Medical Centre, 4 Craven Medical Practice (Affinity Avenue, Care) Thornton, Bradford BD13 3LG Tong Medical Practice 2 Proctor Street, Bradford BD4 9QA Townhead Surgery Townhead, Settle, North Yorkshire, BD24 9JA Valley View Surgery Undercliffe Health Care Centre, 17 Lowther Street, BD2 4RA Wibsey & Queensbury Wibsey Medical Centre, Fair Road, Medical Practice Wibsey, Bradford, BD6 1TD Queensbury Health Centre, Russell Road, Queensbury, BD13 2AG
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Practice Name Address
The Willows (Affinity Care) Osbourne Drive, Queensbury, BD13 2GD Wilsden Medical Practice 2 Ling Bob Court, Wilsden, Bradford BD15 0NJ
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3.2 Nature of Membership and Relationship with CCG
3.2.1 The CCG’s members are integral to the functioning of the CCG. Those exercising delegated functions on behalf of the membership, including the Governing Body and the Senior Leadership Team, remain accountable to the membership.
3.3 Speaking, Writing or Acting in the Name of the CCG
3.3.1 Members are not restricted from giving personal views on any matter. However, members should make it clear that personal views are not necessarily the view of the CCG.
3.3.2 Nothing in or referred to in this constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the CCG, any member of its Governing Body, any member of any of its committees or sub-committees or the committees or sub-committees of its Governing Body, or any employee of the CCG or of any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act.
3.4 Members’ Rights
3.4.1 The CCG’s members have the following rights:
a) Agreeing the overall vision, values and strategic direction of the CCG; b) Calling and attending meetings of the CCG Council; c) Submitting a proposal for amendment of the Constitution and approving relevant constitutional amendments in line with the provisions of Section 1.4 of this constitution; d) Putting themselves forward for appointment to the Senior Leadership Team; e) Appointing members of the Governing Body or Senior Leadership Team; and f) Removing members of the Governing Body or Senior Leadership via a vote of no-confidence.
3.5 Members’ Meetings
3.5.1 Arrangements for meetings of the CCG Council are set out in the CCG Council’s terms of reference which are available in Appendix 2.
3.6 Practice Representatives
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3.6.1 Each member practice has a nominated lead healthcare professional who represents the practice in the dealings with the CCG.
3.6.2 Practice representatives represent their practice’s views and act on behalf of the practice in matters relating to the group. The role of each practice representative is to:
a) represent their appointing practice on the CCG Council b) work with the Senior Leadership Team and Governing Body to support the discharge of their functions c) be responsible for advising the CCG of the views of their practices’ clinicians and patients and provide local intelligence to inform commissioning decisions d) participate in pathway and service redesign, transformational change and the delivery of QIPP, working in partnership with the relevant clinical and managerial leads e) communicate CCG developments and decisions to all members of their appointing practice.
3.6.3 Member practices can remove and replace their nominated representative at any time, by notice in writing to the Chair of the CCG Council. In the event that the nominated representatives are unable to attend, the practice should nominate a deputy and notify the Chair of the CCG Council.
3.6.4 Each member practice authorises its nominated practice representatives to:
a) receive notice of, attend, and vote at any meeting of the CCG Council or sign any written resolution on behalf of that member practice; b) receive distributions on behalf of the member practice; and c) deal with and give directions as to any monies, securities, benefits, documents, notices or other communications (in whatever form) arising by right of or received in connection with the member practices membership of the CCG
3.6.5 Group practices, those operating under a single business operating model but holding individual primary medical services contracts can determine their own representative arrangements providing the representative(/s) is(/are) health care professional(/s).
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4 Arrangements for the Exercise of our Functions
4.1 Good Governance
4.1.1 The CCG will, at all times, observe generally accepted principles of good governance. These include:
a) undertaking regular governance reviews; b) adopting standards and procedures that facilitate speaking out and the raising of concerns including appointment of a Freedom To Speak Up Guardian; c) adopting CCG values that include standards of propriety in relation to the stewardship of public funds, impartiality, integrity and objectivity; d) taking account of The Good Governance Standard for Public Services; e) acting in accordance with the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’; f) acting in accordance with the seven key principles of the NHS Constitution; g) complying with relevant legislation including such as the Equality Act 2010; h) acting in accordance with the standards set out in the Professional Standard Authority’s guidance ‘Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England’; and i) appointing internal and external auditors.
4.2 General
4.2.1 The CCG will:
a) comply with all relevant laws, including regulations; b) comply with directions issued by the Secretary of State for Health or NHS England; c) have regard to statutory guidance including that issued by NHS England; and d) take account, as appropriate, of other documents, advice and guidance.
4.2.2 The CCG will develop and implement the necessary systems and processes to comply with (a)-(d) above, documenting them as necessary in this constitution, its scheme of reservation and delegation and other relevant policies and procedures as appropriate.
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4.3 Authority to Act: the CCG
4.3.1 The CCG is accountable for exercising its statutory functions. It may grant authority to act on its behalf to:
a) any of its members or employees; b) its Governing Body; c) any other committee or sub-committee of the CCG.
4.4 Authority to Act: the Governing Body
4.4.1 The Governing Body may grant authority to act on its behalf to:
a) any member of the Governing Body b) a committee or sub-committee of the Governing Body, or of the CCG; c) a member of the CCG who is an individual (but not a member of the Governing Body); and d) any other individual who may be from outside the organisation and who can provide assistance to the CCG in delivering its functions.
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5 Procedures for Making Decisions
5.1 Scheme of Reservation and Delegation
5.1.1 The CCG has agreed a Scheme of Reservation and Delegation (SoRD) which is published in full here: www.bradfordcravenccg.nhs.uk
5.1.2 The CCG’s SoRD sets out:
a) those decisions that are reserved for the membership as a whole; b) those decisions that have been delegated by the membership to the Governing Body, the Senior Leadership Team or other committees or individuals.
5.1.3 The CCG remains accountable for all of its functions, including those that it has delegated. All those with delegated authority, including the Governing Body and Senior Leadership Team, are accountable to the members for the exercise of their delegated functions.
5.1.4 The Chief Officer may periodically propose amendments to the Scheme of Reservation and Delegation which shall be considered and approved by the Governing Body unless:
Changes are thought to have a material impact; Changes are proposed to the reserved powers of the members or the role and appointment of member practice representatives (including the GP members of the Senior Leadership Team); At least half (50%) of all the Governing Body members formally request that the amendments be put before the membership for approval
5.1.5 Any amendments to the Scheme of Reservation & Delegation approved by the Governing Body will be reported to the CCG Council.
5.2 Standing Orders
5.2.1 The CCG has agreed a set of standing orders which describe the processes that are employed to undertake its business. They include procedures for:
conducting the business of the CCG; the appointments to key roles including Senior Leadership Team and Governing Body members; the procedures to be followed during meetings; and the process to delegate powers.
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5.2.2 The Chief Officer may periodically propose amendments to the Standing Orders which shall be considered and approved by the Governing Body unless:
Changes are thought to have a material impact; Changes are proposed to the reserved powers of the members or the role and appointment of GP members of the Senior Leadership Team; At least half (50%) of all the Governing Body members formally request that the amendments be put before the membership for approval
5.2.3 A full copy of the standing orders is included in Appendix 3. The standing orders form part of this constitution.
5.3 Standing Financial Instructions (SFIs)
5.3.1 The CCG has agreed a set of Standing Financial Instructions (SFIs) which include the delegated limits of financial authority. A copy of the SFIs can be found at www.bradfordcravenccg.nhs.uk
5.3.2 The Chief Officer may periodically propose amendments to the Standing Financial Instructions which shall be considered and approved by the Governing Body unless:
Changes are thought to have a material impact; Changes are proposed to the reserved powers of the members or the role and appointment of member practice representatives (including the GP members of the Senior Leadership Team); At least half (50%) of all the Governing Body members formally request that the amendments be put before the membership for approval
5.3.3 A copy of the Financial Scheme of Delegation (which is an appendix to the SFIs) is included at Appendix 4 and forms part of this constitution.
5.4 The Governing Body: Its Role and Functions
5.4.1 The Governing Body has statutory responsibility for:
a) ensuring that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the CCG’s principles of good governance (its main function); and for b) determining the remuneration, fees and other allowances payable to employees or other persons providing services to the CCG and the allowances payable under any pension scheme established.
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5.4.2 The CCG has also delegated the following additional functions to the Governing Body. Any delegated functions must be exercised within the procedural framework established by the CCG and primarily set out in the Standing Orders (SOs) and Standing Financial Instructions (SFIs):
a) any other function connected with the exercise of its main function as set out in this constitution or specified in regulations; b) receiving assurance on the development of commissioning plans and strategies by the Senior Leadership Team c) approving the CCG’s annual financial plan; d) monitoring performance in line with the CCG’s reporting mechanisms; e) providing assurance to CCG members via the Annual Report that committees are undertaking their functions in accordance with this constitution.
The detailed procedures for the Governing Body, including voting arrangements, are set out in the standing orders.
5.5 Composition of the Governing Body
5.5.1 This part of the constitution describes the make-up of the Governing Body roles. Further information about the individuals who fulfil these roles can be found on our website www.bradfordcravenccg.nhs.uk
5.5.2 The National Health Service (Clinical Commissioning Groups) Regulations 2012 set out a minimum membership requirement of the Governing Body. Managing Conflicts of Interest: revised statutory guidance for CCGs 2017 recommends an additional lay member. The Governing Body will comprise of:
a) The Chair (hereafter referred to as the ‘Clinical Chair’, who is a GP member of the Senior Leadership Team) b) The Accountable Officer (hereafter referred to as the ‘Chief Officer’) c) The Chief Finance Officer d) A Secondary Care Specialist e) A Registered Nurse f) Three Lay Members including: one who has qualifications expertise or experience to enable them to lead on finance and audit matters and who will act as the CCG Conflicts of Interest Guardian; and another who has knowledge about the CCG area enabling them to express an informed view about discharge of the CCG functions.
5.5.3 The CCG has agreed the following additional members:
a) A fourth Lay Member
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b) A GP member of the Senior Leadership Team c) A managerial member of the Senior Leadership Team.
5.5.4 The Deputy Chair of the CCG and the Governing Body will be a Lay Member appointed by the Clinical Chair.
5.5.5 The Senior Independent Director will be a Lay Member appointed by the Clinical Chair in liaison with the Chair of the CCG Council.
5.6 Additional Attendees at Governing Body Meetings
5.6.1 The CCG Governing Body may invite other individuals to attend all or any of its meetings, or part(s) of a meeting, in order to assist it in its decision- making and in its discharge of its functions as it sees fit. Any such person may be invited by the chair to speak and participate in debate, but may not vote.
5.6.2 The following individuals have a standing invitation to attend any or all meetings of the CCG Governing Body as attendees:
a) Chair of the CCG Council b) Director of Public Health, City of Bradford Metropolitan District Council c) Representative from the Bradford District & Craven People’s Board d) Lay Chair of the Individual Funding Request Panel e) Any members of the Senior Leadership Team.
5.7 Appointments to the Governing Body
5.7.1 The process of: appointing GPs to the Governing Body; the selection of the Clinical Chair; and, the appointment procedures for other Governing Body Members are set out in the Standing Orders (Appendix 3 of the constitution).
5.7.2 Also set out in Standing Orders are the details regarding the tenure of office for each role and the procedures for resignation and removal from office.
5.8 Committees and Sub-Committees
5.8.1 The CCG may establish committees and sub-committees of the CCG.
5.8.2 The Governing Body may establish committees and sub-committees.
5.8.3 Each committee and sub-committee established by either the CCG or the Governing Body operates under terms of reference and membership agreed by the CCG or Governing Body as relevant. Appropriate reporting
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and assurance mechanisms must be developed as part of agreeing terms of reference for committees and sub-committees.
5.8.4 With the exception of the Remuneration Committee, any committee or sub-committee established in accordance with clause 5.8 may consist of or include persons other than members or employees of the CCG. All members of the Remuneration Committee will be members of the CCG Governing Body.
5.9 Committees of the CCG
5.9.1 The CCG has established the following committees: Senior Leadership Team and the CCG Council.
5.9.2 Senior Leadership Team is established in accordance with the CCG’s constitution, standing orders and scheme of delegation. The Senior Leadership Team is responsible for leading the vision and strategy, developing commissioning plans and overseeing the commissioning process.
5.9.3 Members of the Senior Leadership Team: the membership of the Senior Leadership Team will comprise, as a minimum six appointed GPs, one of whom will be appointed as the Clinical Chair and one, in addition to their executive role, as Deputy Clinical Chair:
a. Clinical Chair (GP) – co-chair of the Senior Leadership Team with the Chief Officer b. Chief Officer - co-chair of the Senior Leadership Team with the Clinical Chair c. Chief Finance Officer d. Strategic Director of Transformation & Change and Deputy Chief Officer e. Strategic Director of Quality & Nursing f. Strategic Clinical Director of Transformation & Change (GP) g. Strategic Director of Keeping People Well at Home h. Strategic Clinical Director of Keeping People Well in the Community (GP) i. Strategic Clinical Director of Keeping People Well in Hospital (GP) j. Strategic Clinical Director of Strategy & Planning (GP) k. Strategic Clinical Director of Population Health & Wellbeing and Vice-Clinical Chair of the Governing Body (GP) l. Strategic Director of Organisation Effectiveness m. Chief Clinical Information Officer (GP)
The Senior Leadership Team may invite other individuals to attend all or any of its meetings, or part(s) of a meeting, in order to assist it in its decision-making and in its discharge of its functions as it sees fit. Any such person may be invited by the chair to speak and participate in debate, but may not vote.
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5.9.4 The Senior Leadership Team may grant authority to act on its behalf to:
a) any member of the Senior Leadership Team; b) a committee or sub-committee of the Governing Body or of the CCG; c) a member of the CCG who is an individual (but not a member of Senior Leadership Team); and d) any other individual who may be from outside the organisation and who can provide assistance to the CCG in delivering its functions.
5.9.5 The CCG has delegated the following functions to the Senior Leadership Team which are set out in the Scheme of Reservation and Delegation:
a) Leading the setting of vision and strategy b) Developing and approving commissioning plans c) Overseeing the commissioning process d) Overseeing the operating plans of the CCG
5.9.6 The terms of reference of the Senior Leadership Team are included in Appendix 2.
5.9.7 The CCG Council is established in accordance with the CCG’s constitution, standing orders and scheme of delegation. The CCG Council is there to:
a. Represent the interests and statutory responsibilities of the practices as members of the clinical commissioning group b. Be the voice of practices and to ensure effective engagement of all member practices in the development and operation of the CCG; and, c. Be the forum that holds the Governing Body and Senior Leadership Team to account.
5.9.8 Membership and Chair: membership and arrangements for electing the CCG Council Chair are set out in the terms of reference at Appendix 2. A Senior Leadership Team member will not also act as a practice representative. CCG senior managers/officers will be invited to attend.
5.9.9 The CCG has reserved the following functions to the CCG Council which are set out in the Scheme of Reservation and Delegation:
a) Consider, review and approve the CCG’s constitution including Standing Orders b) Approve the process for the appointment of non-elected Governing Body members c) Agree the vision, values and overall strategic direction of the CCG d) Receive the CCG’s annual report and annual accounts.
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The terms of reference of the CCG Council are included in Appendix 2 and further information relating to meetings of the CCG Council as set out in Standing Orders (Appendix 3 of this constitution).
5.10 Committees of the Governing Body
The Governing Body will maintain the following statutory or mandated committees:
5.10.1 Audit & Governance Committee: This Committee is accountable to the Governing Body and provides the Governing Body with an independent and objective view of the CCG’s compliance with its statutory responsibilities. The Committee is responsible for arranging appropriate internal and external audit.
The Audit & Governance Committee will be chaired by the Lay Member who has qualifications, expertise or experience to enable them to lead on finance and audit matters. Members of the Audit & Governance Committee may include individuals who are not Governing Body members.
5.10.2 Remuneration Committee: This committee is accountable to the Governing Body and makes recommendations to the Governing Body about the remuneration, fees, redundancy payments and other allowances (including pension schemes) for employees and other individuals who provide services to the CCG.
The Remuneration Committee will be chaired by a lay member other than the Audit & Governance Committee Chair. Only lay and professional healthcare members of the Governing Body will be members of the Remuneration Committee.
5.10.3 Primary Care Commissioning Committee: this committee is required by the terms of the delegation from NHS England in relation to primary care commissioning functions. The Primary Care Commissioning Committee reports to the Governing Body and to NHS England. Membership of the Committee is determined in accordance with the requirements of Managing Conflicts of Interest: revised statutory guidance for CCGs 2017. This includes the requirement for a lay member Chair and a lay member Deputy Chair. The Audit & Governance Committee Chair may not also act as the Primary Care Commissioning Committee Chair.
5.10.4 None of the above Committees may operate on a joint committee basis with another CCG(s).
5.10.5 The terms of reference for each of the above committees are included in Appendix 2 to this constitution and form part of the constitution.
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5.10.6 The Governing Body have also established a number of other committees to assist with the discharge of their functions. The terms of reference of these committees are published on our website: www.bradfordcravenccg.nhs.uk
5.10.7 The Finance & Performance Committee is established as a committee of the Governing Body. The role of the Finance & Performance Committee is to advise and support the Governing Body through performance oversight of key financial and performance indicators/targets, including Quality, Innovation, Productivity and Prevention (QIPP), as specified in the CCG’s strategic and operational plans.
5.10.8 The Quality Committee is established as a committee of the Governing Body. The role of the Quality Committee is to advise and support the Governing Body in:
a) Providing assurance on the quality of services commissioned; b) Promoting a culture of continuous improvement and innovation with respect to safety of services, clinical effectiveness and patient experience; and c) Identifying issues for escalation to the System Quality Committee for a system-wide quality improvement approach.
The scope of the Quality Committee will be all services commissioned by the CCG including those delegated by NHS England, for children, young people and adults including those services that are jointly commissioned with the local authority and those services commissioned from the voluntary and community sectors.
5.11 Collaborative Commissioning Arrangements
5.11.1 The CCG wishes to work collaboratively with its partner organisations in order to assist it with meeting its statutory duties, particularly those relating to integration. The following provisions set out the framework that will apply to such arrangements.
5.11.2 In addition to the formal joint working mechanisms envisaged below, the Senior Leadership Team may enter into strategic or other transformation discussions with its partner organisations, on behalf of the CCG. Any formal partnership frameworks / agreements arising from such discussions (that lie outside of ‘joint commissioning of services’) will be approved by the Governing Body (for example the West Yorkshire & Harrogate Health and Care Partnership Memorandum of Understanding of the Bradford District & Craven Strategic Partnering Agreement).
5.11.3 The Senior Leadership Team must ensure that appropriate reporting and assurance mechanisms are developed as part of any partnership or other collaborative arrangements. This will include:
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a) reporting arrangements to the Senior Leadership Team, at appropriate intervals; b) engagement events or other review sessions to consider the aims, objectives, strategy and progress of the arrangements; and c) progress reporting against identified objectives.
5.11.4 When delegated responsibilities are being discharged collaboratively, the collaborative arrangements, whether formal joint working or informal collaboration, must:
a) identify the roles and responsibilities of those CCGs or other partner organisations that have agreed to work together and, if formal joint working is being used, the legal basis for such arrangements; b) specify how performance will be monitored and assurance provided to the Senior Leadership Team on the discharge of responsibilities, so as to enable the Senior Leadership Team to have appropriate oversight as to how system integration and strategic intentions are being implemented; c) set out any financial arrangements that have been agreed in relation to the collaborative arrangements, including identifying any pooled budgets and how these will be managed and reported in annual accounts; d) specify under which of the CCG’s supporting policies the collaborative working arrangements will operate; e) specify how the risks associated with the collaborative working arrangement will be managed and apportioned between the respective parties; f) set out how contributions from the parties, including details around assets, employees and equipment to be used, will be agreed and managed; g) identify how disputes will be resolved and the steps required to safely terminate the working arrangements; and h) specify how decisions are communicated to the collaborative partners.
5.12 Joint Commissioning Arrangements with Local Authority Partners
5.12.1 The CCG will work in partnership with its Local Authority partners to reduce health and social inequalities and to promote greater integration of health and social care.
5.12.2 Partnership working between the CCG and its Local Authority partners may include collaborative commissioning arrangements, including joint commissioning under section 75 of the 2006 Act, where permitted by law. In this instance, and to the extent permitted by law, the CCG delegates to the Senior Leadership Team the ability to enter into arrangements with one or more relevant Local Authority in respect of:
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a) delegating specified commissioning functions to the Local Authority; b) exercising specified commissioning functions jointly with the Local Authority; c) exercising any specified health-related functions on behalf of the Local Authority.
5.12.3 For purposes of the arrangements described in 5.12.2, the Senior Leadership Team may:
a) agree formal and legal arrangements to make payments to, or receive payments from, the Local Authority, or pool funds for the purpose of joint commissioning; b) make the services of its employees or any other resources available to the Local Authority; c) receive the services of the employees or the resources from the Local Authority; and d) where the Senior Leadership Team makes an agreement with one or more local authorities as described above, the agreement will set out the arrangements for joint working, including details of:
how the parties will work together to carry out their commissioning functions; the duties and responsibilities of the parties, and the legal basis for such arrangements; how risk will be managed and apportioned between the parties; financial arrangements, including payments towards a pooled fund and management of that fund; contributions from each party, including details of any assets, employees and equipment to be used under the joint working arrangements; and the liability of the CCG to carry out its functions, notwithstanding any joint arrangements entered into.
5.12.4 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.12.2 above.
5.12.5 The Senior Leadership Teamshall require, in all joint commissioning arrangements with local authority partners, that the lead Senior Leadership Team Member for the joint arrangements will:
a) make a quarterly written report to theSenior Leadership Team; b) hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and c) publish an annual report on progress made against objectives.
5.12.6 Should a joint commissioning arrangement with local authority partners prove to be unsatisfactory, the Senior Leadership Team can decide to withdraw from the arrangement but has to give six months’ notice to partners to allow for credible alternative arrangements to be put in place,
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with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
5.13 Joint Commissioning Arrangements – Other CCGs
5.13.1 The CCG may work together with other CCGs in the exercise of its commissioning functions.
5.13.2 The CCG delegates its powers and duties under 5.12 to the Senior Leadership Team and all references in this part to the CCG should be read as the Senior Leadership Team, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements.
5.13.3 The CCG may make arrangements with one or more other CCGs in respect of:
a) delegating any of the CCG’s commissioning functions to another CCG; b) exercising any of the commissioning functions of another CCG; or c) exercising jointly the commissioning functions of the CCG and another CCG.
5.13.4 For the purposes of the arrangements described at 5.12.3, the CCG may:
d) make payments to another CCG; e) receive payments from another CCG; or f) make the services of its employees or any other resources available to another CCG; or g) receive the services of the employees or the resources available to another CCG.
5.13.5 Where the CCG makes arrangements which involve all the CCGs exercising any of their commissioning functions jointly, a joint committee may be established to exercise those functions.
5.13.6 For the purposes of the arrangements described above, the CCG may establish and maintain a pooled fund made up of contributions by all of the CCGs working together jointly pursuant to paragraph 5.13.3 above. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made.
5.13.7 Where the CCG makes arrangements with another CCG as described at paragraph 5.13.3 above, the CCG shall develop and agree with that CCG an agreement setting out the arrangements for joint working including details of:
a) how the parties will work together to carry out their commissioning functions;
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b) the duties and responsibilities of the parties, and the legal basis for such arrangements; c) how risk will be managed and apportioned between the parties; d) financial arrangements, including payments towards a pooled fund and management of that fund; e) contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.13.8 The responsibility of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.12.1 above.
5.13.9 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.12.1 above.
5.13.10 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Senior Leadership Team.
5.13.11 The Senior Leadership Team shall require, in all joint commissioning arrangements with other CCGs, that the lead Senior Leadership Team Member for the joint arrangements:
a) make a quarterly written report to theSenior Leadership Team ; b) hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and c) publish an annual report on progress made against objectives.
5.13.12 Should a joint commissioning arrangement with others CCGs prove to be unsatisfactory the Senior Leadership Team of the CCG can decide to withdraw from the arrangement, but has to give six months’ notice to partners to allow for credible alternative arrangements to be put in place, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
5.14 Joint Commissioning Arrangements with NHS England
5.14.1 The CCG may work together with NHS England. This can take the form of joint working in relation to the CCG’s functions or in relation to NHS England’s functions.
5.14.2 The CCG delegates its powers and duties under 5.14 to the Senior Leadership Team and all references in this part to the CCG should be read as the Senior Leadership Team, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements.
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5.14.3 In terms of either the CCG’s functions or NHS England’s functions, the CCG and NHS England may make arrangements to exercise any of their specified commissioning functions jointly.
5.14.4 The arrangements referred to in paragraph 5.14.3 above may include other CCGs, a combined authority or a local authority.
5.14.5 Where joint commissioning arrangements pursuant to 5.14.3 above are entered into, the parties may establish a joint committee to exercise the commissioning functions in question. For the avoidance of doubt, this provision does not apply to any functions fully delegated to the CCG by NHS England, including but not limited to those relating to primary care commissioning.
5.14.6 Arrangements made pursuant to 5.13.3 above may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.
5.14.7 Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph 5.14.3 above, the CCG shall develop and agree with NHS England a framework setting out the arrangements for joint working, including details of:
a) how the parties will work together to carry out their commissioning functions; b) the duties and responsibilities of the parties, and the legal basis for such arrangements; c) how risk will be managed and apportioned between the parties; d) financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund; e) contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.14.8 Where any joint arrangements entered into relate to the CCG’s functions, the liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.13.3 above. Similarly, where the arrangements relate to NHS England’s functions, the liability of NHS England to carry out its functions will not be affected where it and the CCG enter into joint arrangements pursuant to 5.14.
5.14.9 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.
5.14.10 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Governing Body.
5.14.11 The Senior Leadership Team of the CCG shall require, in all joint commissioning arrangements with NHS England that the lead Senior Leadership Team Member for the joint arrangements will:
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a) make a quarterly written report to theSenior Leadership Team ; b) hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and c) publish an annual report on progress made against objectives.
5.14.12 Should a joint commissioning arrangement with NHS England prove to be unsatisfactory, the Senior Leadership Team can decide to withdraw from the arrangement but has to give six months’ notice to partners to allow for credible alternative arrangements to be put in place, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
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6 Provisions for Conflict of Interest Management and Standards of Business Conduct
6.1 Conflicts of Interest
6.1.1 As required by section 14O of the 2006 Act, the CCG has made arrangements to manage conflicts and potential conflicts of interest to ensure that decisions made by the CCG will be taken and seen to be taken without being unduly influenced by external or private interest.
6.1.2 The CCG has agreed policies and procedures for the identification and management of conflicts of interest.
6.1.3 Employees, members, committee and sub-committee members of the CCG and members of the Governing Body (and its committees, sub- committees, joint committees) will comply with the CCG’s Conflicts of Interest & Standards of Business Conduct Policy.. Where an individual, including any individual directly involved with the business or decision- making of the CCG and not otherwise covered by one of the categories above, has an interest, or becomes aware of an interest which could lead to a conflict of interests in the event of the CCG considering an action or decision in relation to that interest, that must be considered as a potential conflict, and is subject to the provisions of this constitution and the Conflicts of Interest & Standards of Business Conduct Policy.
6.1.4 The CCG has appointed the Audit & Governance Committee Chair to be the Conflicts of Interest Guardian. In collaboration with the CCG’s governance lead, their role is to:
a) act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest; b) be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to conflicts of interest; c) support the rigorous application of conflict of interest principles and policies; d) provide independent advice and judgment to staff and members where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation; and e) provide advice on minimising the risks of conflicts of interest.
6.2 Declaring and Registering Interests
6.2.1 The CCG will maintain registers of the interests of those individuals listed in the CCG’s policy.
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6.2.2 The CCG will, as a minimum, publish the registers of conflicts of interest and gifts and hospitality of decision making staff at least annually on the CCG website and make them available at our headquarters upon request.
6.2.3 All relevant persons for the purposes of NHS England’s statutory guidance Managing Conflicts of Interest: Revised Statutory Guidance for CCGs 2017 must declare any interests. Declarations should be made as soon as reasonably practicable and by law within 28 days after the interest arises. This could include interests an individual is pursuing. Interests will also be declared on appointment and during relevant discussion in meetings.
6.2.4 The CCG will ensure that, as a matter of course, declarations of interest are made and confirmed, or updated at least annually. All persons required to, must declare any interests as soon as reasonably practicable and by law within 28 days after the interest arises.
6.2.5 Interests (including gifts and hospitality) of decision making staff will remain on the public register for a minimum of six months. In addition, the CCG will retain a record of historic interests and offers/receipt of gifts and hospitality for a minimum of six years after the date on which it expired. The CCG’s published register of interests states that historic interests are retained by the CCG for the specified timeframe and details of whom to contact to submit a request for this information.
6.2.6 Activities funded in whole or in part by third parties who may have an interest in CCG business such as sponsored events, posts and research will be managed in accordance with the CCG policy to ensure transparency and that any potential for conflicts of interest are well- managed.
6.3 Training in Relation to Conflicts of Interest
6.3.1 The CCG ensures that relevant staff and all Governing Body and Senior Leadership Team members receive training on the identification and management of conflicts of interest and undertake the NHS England mandatory training.
6.4 Standards of Business Conduct
6.4.1 Employees, members, committee and sub-committee members of the CCG and members of the Governing Body (and its committees, sub- committees, joint committees) will at all times comply with this Constitution and be aware of their responsibilities as outlined in it. They should:
a) act in good faith and in the interests of the CCG; b) follow the Seven Principles of Public Life; set out by the Committee on Standards in Public Life (the Nolan Principles);
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c) comply with the standards set out in the Professional Standards Authority guidance - Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England; and d) comply with the CCG’s Conflicts of Interest & Standards of Business Conduct Policy, including the requirements set out in the policy for managing conflicts of interest, which is available on the CCG’s website and will be made available on request.
6.4.2 Individuals contracted to work on behalf of the CCG or otherwise providing services or facilities to the CCG will be made aware of their obligation with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services and is also outlined in the CCG’s Conflicts of Interest & Standards of Business Conduct Policy.
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Appendix 1: Definitions of Terms Used in This Constitution
2006 Act National Health Service Act 2006
Accountable Officer an individual, as defined under paragraph 12 of Schedule 1A (AO) of the 2006 Act, appointed by NHS England, with responsibility for ensuring the group: complies with its obligations under: sections 14Q and 14R of the 2006 Act, sections 223H to 223J of the 2006 Act, paragraphs 17 to 19 of Schedule 1A of the NHS Act 2006, and any other provision of the 2006 Act specified in a document published by the Board for that purpose; exercises its functions in a way which provides good value for money. Within the CCG, the Accountable Officer is known by the title ‘Chief Officer’.
Area The geographical area that the CCG has responsibility for, as defined in part 2 of this constitution
Clinical Chair The GP appointed by the CCG to act as chair of the CCG and of the Governing Body and co-chair of the Senior Leadership Team.
Deputy Clinical A GP appointed by the Clinical Chair to deputise for him / her Chair on clinical leadership matters and at meetings of the Senior Leadership Team. The Deputy Clinical Chair is not the Deputy Chair of the Governing Body or of the CCG; this role is undertaken by a Lay Member.
Deputy Chair of the A Lay Member (other than the Lay Member for Audit & Governing Body and Governance) appointed by the Clinical Chair to deputise for of the CCG him / her on corporate CCG matters and at meetings of the Governing Body.
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Chief Finance A qualified accountant employed by the group with Officer (CFO) responsibility for financial strategy, financial management and financial governance and who is a member of the Governing Body.
Clinical A body corporate established by NHS England in Commissioning accordance with Chapter A2 of Part 2 of the 2006 Act. Groups (CCG)
Committee A committee created and appointed by the membership of the CCG or the Governing Body.
Sub-Committee A committee created by and reporting to a committee.
Governing Body The body appointed under section 14L of the NHS Act 2006, with the main function of ensuring that a Clinical Commissioning Group has made appropriate arrangements for ensuring that it complies with its obligations under section 14Q under the NHS Act 2006, and such generally accepted principles of good governance as are relevant to it.
Governing Body Any individual appointed to the Governing Body of the CCG Member
Healthcare A Member of a profession that is regulated by one of the Professional following bodies: the General Medical Council (GMC) the General Dental Council (GDC) the General Optical Council; the General Osteopathic Council the General Chiropractic Council the General Pharmaceutical Council the Pharmaceutical Society of Northern Ireland the Nursing and Midwifery Council the Health and Care Professions Council any other regulatory body established by an Order in Council under Section 60 of the Health Act 1999.
Within the CCG the term ‘professional healthcare member of the Governing Body’, refers to the Secondary Care Consultant and Registered Nurse.
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Integrated Care Integrated Care System – the framework within which the System (ICS) NHS and local authorities have come together to plan to improve health and social care over the next few years.
Lay Member A lay member of the CCG Governing Body, appointed by the CCG. A lay member is an individual who is not a member of the CCG or a healthcare professional (as defined above) or as otherwise defined in law.
Primary Care A committee required by the terms of the delegation from Commissioning NHS England in relation to primary care commissioning Committee functions. The Primary Care Commissioning Committee reports to NHS England and the Governing Body
Professional An independent body accountable to the UK Parliament Standards Authority which help Parliament monitor and improve the protection of the public. Published Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England in 2013
Member/ Member A provider of primary medical services to a registered patient Practice list, who is a Member of this CCG.
Member practice Member practices appoint a healthcare professional to act as representative on their practice representative in dealings between it and the the CCG Council CCG, under regulations made under section 89 or 94 of the 2006 Act or directions under section 98A of the 2006 Act.
NHS England The operational name for the National Health Service Commissioning Board.
Registers of Registers a group is required to maintain and make publicly interests available under section 14O of the 2006 Act and the statutory guidance issues by NHS England, of the interests of: the Members of the group; the Members of its CCG Governing Body; the Members of its Committees or Sub-Committees and Committees or Sub-Committees of its CCG Governing Body; and Its employees.
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Senior Leadership An executive committee of the CCG comprising of GPs Team (Strategic Clinical Directors) and managers (Strategic Directors) and co-chaired by the Clinical Chair and Chief Officer.
Sustainability and Sustainability and Transformation Partnerships – the Transformation framework within which the NHS and local authorities have Partnership (STP) come together to plan to improve health and social care over the next few years. STP can also refer to the formal proposals agreed between the NHS and local councils – a “Sustainability and Transformation Plan”.
Joint Committee Committees from two or more organisations that work together with delegated authority from both organisations to enable joint decision-making
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Appendix 2: Committee Terms of Reference
Terms of Reference of Committees of the CCG:
CCG Council
Senior Leadership Team
Terms of Reference of Committees of the Governing Body:
Audit & Governance Committee
Remuneration Committee
Primary Care Commissioning Committee
The Terms of Reference of the Finance & Performance Committee and Quality Committee and any other committees or sub- committees established are held outside of the constitution and are available via our website: www.bradfordcravenccg.nhs.uk
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CCG COUNCIL TERMS OF REFERENCE
1. Role of the Council
The role of the CCG Council is to:
i. represent the interests and statutory responsibilities of the practices as members of the clinical commissioning group,
ii. be the voice of practices and to ensure effective engagement of all member practices in the development and operation of the CCG; and
iii. be the forum that holds the Governing Body and Senior Leadership Team to account.
2. Authority
The CCG Council has the authority, as set out in the CCG constitution to:
i. Agree the vision, values and overall strategic direction of the CCG.
ii. Consider and approve applications to NHS England on any matter concerning changes to the group’s constitution where:
- changes are required for legal reasons - changes are thought to have a material impact - changes are proposed to the reserved powers of the members or the role and appointment of GP members of the Senior Leadership Team); - at least half (50%) of all the Governing Body Members formally request that the amendments be put before the membership for approval.
iii. Consider and approve terms of reference for the Senior Leadership Team and any other committees or sub-committees of the CCG.
iv. Approve arrangements for identifying the group’s proposed Accountable Officer (known as the ‘Chief Officer’).
v. Approve the appointment of Governing Body members (aside from the GP members)
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vi. Remove non-employee members of the Senior Leadership Team or Governing Body via a 75% majority vote of no confidence of those present at the CCG Council meeting where the resolution is passed.
vii. Refer concerns about employee members of the Senior Leadership Team or Governing body to the Clinical Chair for management via the CCG’s HR policies and procedures, following a 75% majority vote of those present at the CCG Council meeting where the resolution is passed.
viii. Receive the group’s annual report and annual accounts at the annual meeting of the CCG Council with members of the Governing Body and Senior Leadership Team.
3. Duties
i. To hold the Governing Body and Senior Leadership Team to account.
ii. To work effectively with all member practices to ensure their contribution to commissioning decisions.
iii. To maintain positive and responsive relationships with NHS England, member practices and Senior Leadership Team members.
iv. To give voice to member practices by ensuring members are engaged, informed and empowered to participate in the development of the strategic direction of the CCG.
v. To represent their practice’s views and act on behalf of the practice in order to influence the strategic and commissioning intentions of the CCG.
vi. To seek advice and views of the practice members of the CCG.
vii. To facilitate effective two way communication between members and the CCG Governing Body and Senior Leadership Team.
viii. To shape a culture of continuously improving the services for patients, carers, communities and member practices within the resources available.
4. Membership and Chair
i. A clinical representative (i.e. a healthcare professional as defined in Appendix 1 of the constitution) from each of the CCG’s member practices to attend the CCG Council.
ii. Nominated practice representatives may send a deputy to attend CCG Council. The deputy must be a clinician.
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iii. A Senior Leadership Team member will not also act as a practice representative at the CCG Council.
iv. The Chair of the CCG Council must be a clinician representing one of the CCG’s member practices at the CCG Council. The Chair will be elected (for a three year term of office, with a maximum term of nine years) on behalf of the membership by the member practice representatives attending the CCG Council. Should there be no alternative candidates, the CCG Council may appoint the incumbent Chair for a further term of office.
v. The Chair of the CCG Council will nominate another practice representative member of the council to deputise for them in case of absence.
vi. CCG senior managers/officers will be invited to attend.
5. Engagement
Every practice nominates a clinician to represent their practice at the CCG Council.
Group practices, those operating under a single business operating model but holding individual primary medical services contracts can determine their own representative arrangements providing the representative(/s) is(/are) health care professional(/s).
The representative will need to be able to work effectively with GPs, and with other practice staff, to feed the practice’s views into commissioning decisions. (For more details, please see Appendix A: Role and Responsibilities of Practice Representatives).
6. Voting
Every member of the CCG Council (or their deputy) will have one vote.
In the event of an equality of votes, the chair of the meeting shall have the casting vote.
Where a vote occurs, the outcomes of the vote, how each member practice voted and any dissenting views will be recorded in the minutes of the meeting.
7. Quorum
For the CCG Council to transact business and make decisions 50% of the member practices must be represented. Officers attending the CCG Council will give advice and not have a vote at the meeting.
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8. Frequency and type of meetings
The CCG Council will meet at least twice a year, including the Annual General Meeting with the Senior Leadership Team and the Governing Body.
An extraordinary meeting of the CCG Council can be called by at least 60% of member practices submitting such a request to the Chair of the CCG Council; at least 10 working days’ notice will be given of such a meeting.
9. Urgent matters arising between meetings
The Chair of the CCG Council, in consultation with the Chief Officer, or the Clinical Chair, may act on urgent matters of CCG Council business arising between meetings.
Where an urgent decision has been taken, this will be notified to CCG Council members by email. A formal report will then be taken to the next meeting of the CCG Council, where the Chair will explain the reason for the action taken.
10. Accountability
The CCG Council is accountable to the member practices of the CCG.
11. Reviews and reports
Outcomes of meetings will be communicated to all member practices and the Senior Leadership Team. Updates on CCG Council meetings will also be included in the Clinical Chair’s and / or Chief Officer’s written report to the Governing Body.
The dates of the meetings will be published annually and agendas and reports for the meetings will be circulated five working days before the meeting.
Draft minutes of the meeting will be subject to ratification at the next CCG Council.
The CCG Council will review its compliance with its terms of reference and the terms of reference document itself annually (during Quarter 1 of the year) and will periodically review its own effectiveness
12. Conduct
The CCG Council will have due regard to, and operate within, the constitution, standing orders, scheme of delegation and reservation, prime financial policies and other policies and procedures of the CCG.
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The CCG Council will adhere to the CCG’s Conflict of Interest and Business Conduct Policy.
Except where an interest is acknowledged at the meeting by the Chair as generic to all CCG practices, any member who has an actual or potential conflict of interest in any matter on the agenda and who is present at the meeting at which the matter is under discussion, will declare that interest:
At the start of the meeting Again at the relevant agenda item
All declarations will be recorded in the minutes of the meeting and the Chair of the meeting will determine how the interest will be managed in accordance with the CCG Conflicts of Interest and Business Conduct Policy.
In making this decision, the Chair will need to consider the following points:
the nature and materiality of the decision the nature and materiality of the declared interest(s) the availability of relevant expertise as a general rule (and subject to the judgement of the Chair), if an interest involves a pecuniary interest or a significant non-pecuniary interest, the individual should be asked to leave the meeting for the whole item.
The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned:
take part in the discussion but not in the decision-taking not take part in either the discussion or decision-taking take part in the discussion and left the meeting for the decision or left the meeting for the whole of the item.
Appendix A: Role and Responsibilities of Practice Representatives
Appendix B: Dispute Resolution Procedure
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APPENDIX A: Role and Responsibilities of Practice Representatives (extract from Section 3.6 of the constitution)
Practice Representatives
Each member practice has a nominated lead healthcare professional who represents the practice in the dealings with the CCG.
Practice representatives represent their practice’s views and act on behalf of the practice in matters relating to the group. The role of each practice representative is to: a) represent their appointing practice on the CCG Council. b) work with the Senior Leadership Team and Governing Body to support the discharge of their functions c) be responsible for advising the CCG of the views of their practices clinicians and patients and provide local intelligence to inform commissioning decisions d) participate in pathway and service redesign, transformational change and the delivery of QIPP, working in partnership with the relevant clinical and managerial leads e) monitor and review the effectiveness of the Senior Leadership Team and Governing Body f) communicate CCG developments and decisions to all members of their appointing practice
Member practices can remove and replace nominated representatives at any time, by notice in writing to the chair of the CCG Council. In the event that the nominated representatives are unable to attend, the practice should nominate a deputy and notify the chair of the CCG Council.
Each member practice authorises its nominated representative to: a) receive notice of, attend, and vote at any meeting of the CCG Council whether on a show of hands or on a poll, or sign any written resolution on behalf of that member practice b) receive distributions on behalf of the member practice c) deal with and give directions as to any monies, securities, benefits, documents, notices or other communications (in whatever form) arising by right of or received in connection with the member practices membership of the CCG
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APPENDIX B: Dispute Resolution Procedure For disputes between the CCG Council and the Senior Leadership Team and or the Governing Body
NOTE: It is possible to call an extraordinary general meeting and propose a motion of no confidence in a member or members of the Senior Leadership Team and / or Governing Body (as set out in paragraph 1.7 below and in sections 2.2.15 and 2.2.1 of Standing Orders) at any time. The steps set out in paragraphs 1.1 to 1.6 are a suggested pre-cursor to this measure.
1.1 Where there are concerns that the Senior Leadership Team and or the Governing Body has either acted unreasonably, or taken a decision with which member practices disagree, concerns can be raised by a majority vote of the CCG Council in support of challenge.
1.2 The first stage to address any concern is for the Senior Leadership Team and or the Governing Body to be asked to suspend further action and for the proposal to be taken to the CCG Council for consideration and agreement.
1.3 Practice representatives will then be called to a Special General Meeting with a minimum of 10 working days’ notice. All practice representatives will be provided with background information relating to the discussion to be held in advance of the meeting, which outlines the reasons why it is considered that the Senior Leadership Team and or the Governing Body has acted inappropriately to enable them to consider the matter in question.
1.4 If it is considered by the CCG Council that the Senior Leadership Team and or the Governing Body continues to act inappropriately, a 66% majority vote of those present at the Special General Meeting is required in order to censure any decision or action, inform the Senior Leadership Team and or Governing Body it has done so and request a meeting with the Senior Leadership Team and or the Governing Body.
1.5 Such a meeting will at a minimum include the Clinical Chair and the Chief Officer, who will be invited to attend the meeting to answer questions relating to Senior Leadership Team and or Governing Body actions. A minimum of 10 working days’ notice of the meeting will be given and background information provided to the Senior Leadership Team and or the Governing Body regarding the CCG Council’s concerns.
1.6 If a resolution is not achieved at such a meeting, independent arbitration will be sought to work together with representatives of the Senior Leadership Team and or the Governing Body and the CCG Council in an attempt to resolve the dispute.
1.7 In the event that the member practices express a loss of confidence in a member/s of the Senior Leadership Team and or the Governing Body, then an Extraordinary General Meeting may be called by at least a 60% majority vote
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by the CCG Council with a minimum of 10 working days’ notice. A motion of no confidence can be passed by at least a 75% majority vote of those present at the Extraordinary General Meeting in order to:
(a) Remove non-employee members of the Senior Leadership Team and or Governing Body, or; (b) Refer concerns about employee members of the Senior Leadership Team and or Governing Body to the Clinical Chair for resolution under the CCG’s HR policies and procedures, or; (c) Refer concerns about the actions and or decisions of the Senior Leadership Team and / or Governing Body to NHS England.
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Senior leadership team – terms of reference v2.0
1. Accountability arrangements and authority The senior leadership team (SLT) is established in accordance with NHS Bradford District and Craven CCG’s constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the senior leadership team and shall have effect as if incorporated into the CCG’s constitution.
The senior leadership team is established as a committee of the CCG accountable to the CCG Council.
The senior leadership team is authorised by the CCG Council to investigate any activity within its terms of reference. It is authorised to seek any information it requires within its remit, from any employee of the CCG or any member of the Governing Body and they are directed to co-operate with any request made by the SLT within its remit as outlined in these terms of reference.
The senior leadership team is authorised to commission reports or surveys it deems necessary to help fulfil its obligations.
The senior leadership team is authorised to obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary. In doing so the committee must follow any procedures put in place by the CCG for obtaining legal or professional advice.
2. Relationships and reporting The senior leadership team is accountable to the CCG Council.
The minutes of SLT meetings shall be formally recorded and circulated to members for approval at a subsequent meeting.
Outcomes of SLT meetings will be communicated in writing to the Governing Body via the clinical chair’s and chief officer’s report, with updates to the CCG Council and/or direct reporting to member practices as appropriate. Reports on specific issues shall be prepared for consideration by the CCG Council or Governing Body as appropriate.
The co-chairs will draw to the attention of the CCG Council and the Governing Body any significant risks or issues arising from the work of SLT.
The senior leadership team will approve an annual report of its work to the CCG Council via the CCG’s Annual Report. As required by CCG Annual Report guidance this will, as a minimum, include information about: key responsibilities, membership, attendance record and highlights of the work of SLT during the year.
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3. Role and responsibilities The role of the senior leadership team is to: a) lead the development of CCG vision and strategy b) develop and approve commissioning plans and policies c) oversee the commissioning process d) oversee the operating plans of the CCG
The responsibilities of the senior leadership team include: approve the CCG’s commissioning plan, policies and strategies
approval of any arrangements for the joint commissioning of services with local authorities, other CCGs or NHS England
approve arrangements for the joint commissioning of services with other CCGs, NHS England or with local authorities (including) approval of any terms of reference for joint committees), unless otherwise delegated to the Governing Body
make decisions on the review, planning and procurement of services (except those where authority has been delegated to another group, for example the Primary Care Commissioning Committee or the Joint Committee of West Yorkshire and Harrogate CCGs)
inform CCG input and voting at the Joint Committee of West Yorkshire and Harrogate CCGs
approve arrangements for managing individual funding requests
approve, following consultation with the BDCFT staff partnership forum and, where agreed, CCG staff networks, human resource policies for employees and for other persons working on behalf of the CCG
4. Membership The membership of the senior leadership team will comprise as a minimum of:
Clinical chair (GP) Four appointed GPs including: - Strategic clinical director of transformation and change - Strategic clinical director of keeping well - Strategic clinical director of population health and wellbeing - Strategic clinical director of strategy and planning Chief clinical information officer (GP)
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Chief officer Chief finance officer Strategic director of transformation and change Strategic director of keeping well Strategic director of quality and nursing Strategic director of organisation effectiveness
5. Chair The senior leadership team will be co-chaired by the clinical chair and the chief officer. The clinical chair will select one of the strategic clinical directors to act as the deputy clinical chair of the senior leadership team. The chief officer will appoint one of the strategic directors to act as the deputy chief officer of the senior leadership team.
6. Quorum The quorum shall be 50% of the senior leadership team and include: One of the co-chairs or the deputy clinical chair or the deputy chief officer; At least three GP members of the SLT; and At least three non-GP members of the SLT.
7. Decision making and voting Generally it is expected that meeting decisions will be reached by consensus. Should this not be possible, each member of the senior leadership team will have one vote. Decisions will be by majority vote. In the event of a tied vote, the chair of the senior leadership team meeting will have a second and casting vote. Should a vote be taken, the outcome of the vote and dissenting views will be recorded in the minutes of the meeting.
8. In attendance Senior members of staff and other individuals will be invited to attend senior leadership team meetings as appropriate. In order to support continuity in engagement and strategic decision making, non-GP members of the senior leadership team may nominate deputies to attend on their behalf.
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Deputies (of non-GP, i.e. managerial members of SLT) will count towards quorum but will not have voting rights unless they have formal acting up status.
9. Meetings The senior leadership team will usually meet weekly (in person and/or virtually, e.g. via videoconference) and will have the contingency to call other meetings as appropriate. The agenda and papers will be circulated to members and relevant parties at least two working days in advance of the meeting date.
10. Sub-groups The senior leadership team may establish sub-committees or groups to support it in its role. However, they may only delegate responsibility and authority to a sub- committee or group if expressly authorised to do so by the CCG Council (via an amendment to these terms of reference).
The senior leadership team has established the Individual Funding Requests Panel (IFRP) and the associate leadership team (ALT) as sub-committees of the senior leadership team. The terms of reference of the IRFP and the ALT are approved by the senior leadership team.
11. Code of conduct The senior leadership team will conduct its business in accordance with relevant national guidance and codes of practice such as the Nolan Principles of Public Life. The senior leadership team will apply best practice in its decision making processes and will comply with the CCG constitution, standing orders, scheme of delegation and standing financial instructions. The senior leadership team will ensure good clinical and corporate governance at all times.
12. Management of conflicts of interest The senior leadership team will adhere to the CCG’s Business Conduct and Conflicts of Interest Policy.
If any member of the senior leadership team has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The chair of the
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meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct and Conflicts of Interest Policy.
The minutes must specify how the chair decided to manage the declared interest, i.e. did the individual(s) concerned:
Take part in the discussion but not in the decision-taking? Not take part in either the discussion or decision-taking? Take part in the discussion and left the meeting for the decision? or Left the meeting for the whole of the item?
In making this decision the chair will need to consider the following points:
The nature and materiality of the decision. The nature and materiality of the declared interest(s). The availability of relevant expertise. As a general rule (and subject to the judgement of the chair), if an interest involves a pecuniary interest or a significant non-pecuniary interest, the individual should be asked to leave the meeting for the whole item.
If all GP members of the senior leadership team are conflicted, or sufficient members conflicted to result in the SLT being inquorate, the decision will be referred to the Governing Body for resolution.
13. Administration and support The strategic director of organisation effectiveness will provide support to the committee and will develop and maintain a work programme to guide and inform the work of the senior leadership team. The strategic director of organisation effectiveness will be responsible for supporting the co-chairs of the senior leadership team in the management of the committee’s business and for drawing the committee’s attention to best practice, national guidance and other relevant documents as appropriate.
14. Urgent matters arising between meetings The co-chairs of the senior leadership team in consultation with one or more SLT members may act on urgent matters arising between meetings. Such matters will be reported to the next meeting of the senior leadership team.
15. Monitoring of performance and compliance The senior leadership team will review its own effectiveness, its compliance with its terms of reference and the terms of reference document itself at least annually. A
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report of the outcomes of this review will be reported to the Governing Body (or the Audit and Governance Committee on behalf of the Governing Body).
16. Terms of reference review date and approving body Terms of reference will be reviewed annually (quarter one of the year), or as and when legislation or relevant guidance is updated. Any amendments to the terms of reference will be agreed by the senior leadership team for recommendation for approval by the subsequent meeting of the CCG Council.
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AUDIT & GOVERNANCE COMMITTEE TERMS OF REFERENCE V2.0
1. Accountability Arrangements and Authority
The Audit and Governance Committee (the committee) is established in accordance with NHS Bradford District and Craven CCG’s constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the committee and shall have effect as if incorporated into the CCG’s constitution.
The Audit and Governance Committee is accountable to the Governing Body.
The Audit and Governance Committee is authorised by the Governing Body to investigate any activity within its terms of reference. It is authorised to seek any information it requires within its remit, from any employee or member of the Governing Body or Senior Leadership Team and they are directed to co-operate with any request made by the Committee within its remit as outlined in these terms of reference.
The Audit and Governance Committee is authorised to commission report or surveys it deems necessary to help fulfil its obligations.
The Audit and Governance Committee is authorised to obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary. In doing so the committee must follow any procedures put in place by the Governing Body for obtaining legal or professional advice.
2. Relationships and Reporting
The Audit and Governance Committee is accountable to the CCG Governing Body.
The minutes of the Audit and Governance Committee shall be formally recorded and submitted to the Governing Body. The Chair of the Audit and Governance Committee shall draw to the attention of the Governing Body any significant issues or risks. Reports on specific issues shall be prepared for consideration by the Governing Body as appropriate.
The Audit and Governance Committee will report to the Governing Body at least annually on its work in support of the Annual Governance Statement, specifically commenting on:
the performance of the committee and its review of its terms of reference the fitness for purpose of the Commissioning Assurance Framework the completeness and embeddedness of risk management the effectiveness of integrated governance
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the appropriateness of the evidence to support compliance with the ‘going concern’ principle (i.e. continuing existence as a functioning organisation) details of any significant issues in relation to the financial statements and how these were addressed
3. Role and function
The role of the Audit and Governance Committee is to review and provide assurance to the Governing Body on the adequate and effective operation of the CCG’s overall internal control system, with particular responsibilities related to financial reporting and management.
The Audit and Governance Committee will also ensure an appropriate relationship is maintained with both the internal and external auditors.
Under Section 5 of the Constitution, the Audit and Governance Committee is charged with providing assurance to the Governing Body on the following functions:
Ensuring that expenditure does not exceed the aggregated of its allotments for the financial year. Ensuring the CCG’s use of resources does not exceed the amount specified by NHS England for the financial year. Taking account of any directions specified by NHS England in respect of specified resource use. Publishing an explanation of how the Group spent any payment in respect of quality made to it by NHS England.
The work of the committee will be flexible to new and emerging priorities and risks.
The Audit and Governance Committee, or a sub-set of it, will also act as the ‘Auditor Panel’ for the appointment of the External Auditor, as required by the Local Audit & Accountability Act 2014 and the Local Audit (Health Service Bodies Auditor Panel and Independence) Regulations 2015.
4. Responsibilities
The Audit and Governance Committee is responsible for reviewing the arrangements for integrated governance and risk management activities within the CCG.
The Audit and Governance Committee shall critically review the CCG’s financial reporting and internal control principles and ensure an appropriate relationship with both internal and external auditors is maintained.
The key duties of the Audit and Governance Committee are as follows:
4.1 Integrated Governance, Risk Management and Internal Control
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The Audit and Governance Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities. The Audit and Governance Committee will also approve the CCG’s risk management arrangements via approval of the Integrated Risk Management Framework.
In particular, the Audit and Governance Committee will review the adequacy and effectiveness of:
All risk and control related disclosure statements (in particular the Annual Governance Statement), together with any appropriate independent assurances. The underlying assurance processes that indicate the degree of achievement of the CCGs objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements. The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification. The policies and procedures for all work related to anti-bribery, fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud Authority.
In carrying out this work the Audit and Governance Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It may seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.
This will be evidenced through the Audit and Governance Committee use of an effective assurance framework to guide its work and that of the audit and assurance functions that report to it.
4.2 Financial Reporting
The Audit and Governance Committee shall monitor the integrity of the financial statements of the CCG and any formal announcements relating to the CCGs financial performance.
The Audit and Governance Committee shall ensure that the systems for financial reporting to the CCG, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the CCG.
The Audit and Governance Committee shall review and approve the annual report and financial statements prior to presentation to the CCG Council, focusing particularly on:
The wording in the governance statement and other disclosures relevant to the terms of reference of the committee;
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Changes in, and compliance with, accounting policies, practices and estimation techniques; Unadjusted mis-statements in the financial statements; Significant judgements in preparing of the financial statements; Significant adjustments resulting from the audit; Letter of representation; and Qualitative aspects of financial reporting.
4.3 Internal Audit
The Audit and Governance Committee shall ensure that there is an effective internal audit function that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the committee, Chief Officer and CCG. This will be achieved by:
Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal. Review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the assurance framework. Considering the major findings of internal audit work (and management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources. Ensuring that the internal audit function is adequately resourced and has appropriate standing within the clinical commissioning group. An annual review of the effectiveness of internal audit.
The Audit and Governance Committee will meet privately with Internal Audit at least annually.
4.4 External Audit
The Audit and Governance Committee shall review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:
Consideration of the performance of the external auditors, as far as the rules governing the appointment permit. Discussion and agreement with the external auditors, before the audit commences, on the nature and scope of the audit as set out in the annual plan, and ensuring co-ordination, as appropriate, with other external auditors in the local health economy. Discussion with the external auditors of their local evaluation of audit risks and assessment of the CCG and associated impact on the audit fee. Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the clinical
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commissioning groups and any work undertaken outside the annual audit plan, together with the appropriateness of management responses. An annual review of the effectiveness of external audit.
The Audit and Governance Committee will meet privately with External Audit at least annually.
The Audit and Governance Committee, or a sub-set of it, will also act as the ‘Auditor Panel’ for the appointment of the External Auditor, as required by the Local Audit & Accountability Act 2014 and the Local Audit (Health Service Bodies Auditor Panel and Independence) Regulations 2015. The Auditor Panel will:
Advise the CCG’s Governing Body on the selection and appointment of the External Auditor. Ensure that a notice is published on their website within 28 days of appointing the External Auditor providing details of the appointment made and the advice given by the Auditor Panel (and the reasons for not following this advice if the CCG’s Governing Body so chose). Ensure that if the CCG fails to appoint an External Auditor, that this is notified to NHS England by the 25th March in the preceding financial year. Advise the CCG’s Governing Body on the purchase of any ‘non-audit services’ from the External Auditor. Advise the CCG’s Governing Body on the ongoing maintenance of an independent relationship with the External Auditor.
4.5 Counter Fraud and Security Management
The Audit and Governance Committee shall satisfy itself that the CCG has adequate arrangements in place for countering fraud, bribery and corruption. This shall be achieved by:
Approving the local counter fraud plan and monitoring its implementation. Receiving updates on local counter fraud cases. Receiving briefings/updates on national counter fraud issues as appropriate.
The Audit and Governance Committee shall satisfy itself that the CCG has adequate arrangements in place for security management. This shall be achieved by:
Approving the local security management plan (as part of the health, safety and security management work-plan) and monitoring its implementation. Receiving updates on local security management cases. Receiving briefings/updates on national security management issues as appropriate.
4.6 Information Governance / Data Security & Protection
The Audit and Governance Committee shall maintain an overview of the adequacy and effectiveness of Information Governance / Data Security & Protection across the
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whole of the CCG’s activities and provide assurance to the Governing Body that associated risks are being managed, highlighting any significant risks and related resource implications where these arise.
The Audit and Governance Committee shall achieve this by:
Monitoring the delivery of the annual information governance work programme. Seeking assurance that effective arrangements are in place for information governance, ensuring that any risks and incidents are appropriately managed and reported. Seeking assurance that resources and systems are in place to support the delivery of the Data Security and Protection Toolkit and to receive an exception report on any significant risks or gaps in compliance; Receiving and considering reports into breaches of confidentiality and security, other relevant incidents, audit and data quality reports. Reviewing and recommending relevant policies, guidelines and procedures for approval. Seeking assurance that the CCG is fulfilling statutory duties regarding the Freedom of Information Act 2000.
4.7 Health and Safety
The Audit and Governance Committee shall maintain an overview of the adequacy and effectiveness of health and safety across the whole of the CCG’s activities and provide assurance to the Governing Body that risks associated with health and safety are being managed, highlighting any significant risks and related resource implications where these arise.
The Audit and Governance Committee shall achieve this by:
Monitoring the delivery of the annual health and safety work programme. Seeking assurance that effective arrangements are in place for health and safety, ensuring that any risks and incidents are appropriately managed and reported. an exception report on any significant risks or gaps in compliance; Receiving and considering reports into any health and safety risk assessments, incidents, etc. Reviewing and recommending relevant policies, guidelines and procedures for approval.
4.8 Other Assurance Functions
The Audit and Governance Committee shall review the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the clinical commissioning group.
These will include, but will not be limited to, any reviews by Department of Health arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission or NHS Litigation Authority) and professional bodies with responsibility
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for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).
4.9 Management
The Audit and Governance Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
The Audit and Governance Committee may also request specific reports from individual functions within the CCG as they may be appropriate to the overall arrangements.
4.10 Whistle Blowing
To review the effectiveness of the arrangements in place for allowing staff or Senior Leadership Team / Governing Body members to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently. Any issues raised under the formal stage of the policy will be reported to the Audit and Governance Committee.
4.11 Other Duties
To approve policies in respect of all areas of the committee’s responsibilities. To consider and make recommendations to the Senior Leadership Team or Governing Body in respect of strategies on all areas of the committee’s responsibilities. To receive and review reports on waivers of Standing Orders and Standing Financial Instructions that have taken place or on any issues relating to compliance with these documents. To receive and review the Register of Application of the Seal To receive and review the Register of Interests and Register of Procurement Decisions. To receive and review reports on standards of business conduct/receipts of gifts, hospitality and sponsorship, including the management of Conflicts of Interest. To undertake a periodic review of Standing Orders, SFIs and the Scheme of Delegation. To undertake an annual review of the Committee’s own effectiveness. To received assurance on the annual review of effectiveness of other CCG committees on behalf of the Governing Body.
5. Membership
The Audit & Governance Committee will comprise of not fewer than three members drawn from the Lay and Professional Healthcare members of the Governing Body.
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The Audit and Governance Committee may include additional individuals who are not members of the Governing Body.
Members of the Audit & Governance Committee are appointed by the Governing Body.
6. Chair
The Audit and Governance Committee will be chaired by a Lay Member who has qualifications, expertise or experience to enable them to lead on finance and audit matters (this shall not be the same Lay Member who chairs the Primary Care Commissioning Committee).
7. Decision-making and Voting
Generally, it is expected that meeting decisions will be reached by consensus. Should this not be possible, each member of the Audit and Governance Committee will have one vote. Decisions will be by majority vote.
In the event of a tied vote, the Chair of the committee will have a second and casting vote.
Should a vote be taken, the outcome of the vote will be recorded in the minutes of the meeting.
8. Quorum
Quorum shall be two members of the Audit and Governance Committee. If the committee is not quorate the meeting may be postponed at the discretion of the chair. If the meeting does take place and is not quorate, no decisions shall be made at that meeting and such matters must be deferred until the next quorate meeting (or may be subject to determination by email exchange).
9. In Attendance
A representative from Internal Audit, a representative from External Audit, the chief finance officer, the strategic director of organisation effectiveness, strategic head of assurance and the head of governance shall normally attend meetings.
In addition:
At least once a year the committee will meet privately with the external and internal auditors. Regardless of attendance, external audit, internal audit, local counter fraud and security management providers will have full and unrestricted rights of access to the Audit and Governance Committee. The chief officer should be invited to attend and discuss, at least annually with the committee, the process for assurance that supports the statement on internal
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control. He or she should also normally attend when the committee considers the draft internal audit plan and the annual accounts. Any other member of the CCGs leadership team may be invited to attend, particularly when the committee is discussing areas of risk or concern.
The Chair is also invited to attend one meeting each year in order to form a view on, and understanding of, the committee’s operations.
10. Meetings
Meetings shall be held not less than four times a year.
A minimum of ten days’ notice should be given when calling a meeting.
The meeting will be called by the Chair of the Committee.
The External Auditor or Head of Internal Audit may request a meeting if they consider that one is necessary and this may be called at shorter notice than stated above
11. Sub-Committees / Groups
The Audit and Governance Committee may establish sub-committees or groups to support it in its role. However, they may only delegate responsibility and authority to a sub-committee or group, if expressly authorised to do so by the Governing Body.
12. Conduct
The Audit and Governance Committee will conduct its business in accordance with relevant national guidance, including the NHS Audit Committee Handbook and codes of practice such as the Nolan Principles.
13. Management of Conflicts of Interest
The Audit and Governance Committee will adhere to the CCG’s Business Conduct & Conflicts of Interest Policy.
If any member of the committee has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The Chair of the meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct & Conflicts of Interest Policy.
The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned:
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Take part in the discussion but not in the decision-taking? Not take part in either the discussion or decision-taking? Take part in the discussion and left the meeting for the decision? or Left the meeting for the whole of the item?
In making this decision the Chair will need to consider the following points:
The nature and materiality of the decision. The nature and materiality of the declared interest(s). The availability of relevant expertise. As a general rule (and subject to the judgement of the Chair), if an interest involves a financial interest or a significant non-financial interest, the individual should be asked to leave the meeting for the whole item.
14. Administration
The Governance team will provide administrative support to the committee and will ensure that papers are issued at least five working days before a meeting and that draft minutes are circulated within ten working days after a meeting. The Governance team will be responsible for supporting the chair in the management of the committee’s business and for drawing the committee’s attention to best practice, national guidance and other relevant documents as appropriate. The Governance team in conjunction with the Chair of the Audit and Governance Committee will develop and maintain a work programme to inform and guide the work of the committee.
15. Urgent Matters Arising Between Meetings
The Chair of the Audit and Governance Committee in consultation with either the chief finance Officer or the chief officer may also act on urgent matters arising between meetings.
In the absence of the Chair, one of the other Audit and Governance Committee members and either the chief finance officer or chief officer may act together.
These matters will be ratified at the next meeting of the committee.
16. Monitoring of Performance and Compliance
The Audit and Governance Committee will review its own effectiveness, its compliance with its terms of reference and the terms of reference document itself at least annually and a report of the outcomes of this review will be produced and reported to the Governing Body.
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The Governing Body is responsible for monitoring the performance of the committee through receipt of its minutes and Annual Report.
17. TOR Review and Approving Body
Terms of Reference will be reviewed annually (during Quarter 1 of the year) or as and when legislation or best practice guidance is updated.
Any amended Terms of Reference will be agreed by the Audit and Governance Committee for recommendation for approval by a subsequent meeting of the Governing Body.
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REMUNERATION COMMITTEE TERMS OF REFERENCE
1. Accountability Arrangements and Authority
The Remuneration Committee (the committee) is established in accordance with NHS Bradford District and Craven CCG’s constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the committee and shall be incorporated into the CCG’s constitution.
It is the responsibility of the Governing Body to made decision about the pay of employees and other persons providing services to the CCGs, acting upon the advice of the Remuneration Committee.
The Remuneration Committee is accountable to the Governing Body.
The Remuneration Committee is authorised by the Governing Body to investigate any activity within its terms of reference. It is authorised to seek any information it requires within its remit, from any employee or member of the Governing Body or Senior Leadership Team and they are directed to co-operate with any request made by the committee within its remit as outlined in these terms of reference.
The Remuneration Committee is authorised to commission report or surveys it deems necessary to help fulfil its obligations.
The Remuneration Committee is authorised to obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary. In doing so the committee must follow any procedures put in place by the Governing Body for obtaining legal or professional advice.
2. Relationships and Reporting
The Remuneration Committee is accountable to the CCG Governing Body.
The minutes of the Remuneration Committee shall be formally recorded and submitted to the members within ten days of a meeting for ratification by email.
The Remuneration Committee will report on its meetings via a summary report to the Governing Body in private session and will seek approval from the Governing Body of any recommendations made by the Committee about pay, fees or other allowances payable to employees or other persons who provides services to the CCGs. Sufficient information will be provided to the Governing Body to explain the rationale for the Committee’s recommendations.
The Chair of the Remuneration Committee will draw the attention of the Governing Body to any significant issues or risks arising from the work of the Committee.
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The Remuneration Committee will provide an annual report of its work to the Governing Body and the CCG Council via the CCG’s Annual Report. As required by CCG Annual Report guidance this will, as a minimum, include information about: key responsibilities, membership, attendance records and highlights of the Committee’s work over the year.
3. Role and responsibilities
The Committee shall make recommendations to the Governing Body about pay, remuneration and conditions of service for employees of the CCG and people who provide services to the CCG (such as clinical leaders) and allowances under any pension scheme it might establish as an alternative to the NHS pension scheme.
Specifically that the Committee will:
Recommend to the Governing Body the terms and conditions, remuneration and travelling or other allowances, including pensions and gratuities for Governing Body members (excluding the Lay Members), GP members of the Senior Leadership Team and the Chair of the CCG Council.
Recommend to the Governing Body arrangements for the determination of terms and conditions of employment for all employees of the group including, pensions, remuneration, fees and travelling or other allowances payable to employees and to other persons providing services to the group.
Recommend to the Governing Body any salary increases outside of Agenda for Change. Recommend to the Governing Body any severance payments made to any employee, seeking HM Treasury approval as appropriate. Receive assurance on the annual performance and objective setting process and its outcomes for the Clinical Chair, the Chief Officer and all other members of the Senior Leadership Team. Approve the disciplinary policy and procedure for the CCG.
4. Membership
The Remuneration Committee is a non-executive committee and shall be appointed by the CCG from amongst its Governing Body members. Only Governing Body members may be members of the Remuneration Committee.
The Remuneration Committee will comprise of not fewer than three members drawn from the Lay and Professional Healthcare members of the Governing Body.
5. Chair
The Remuneration Committee will be chaired by one of the Lay Members other than the Chair of the Audit & Governance Committee.
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6. Quorum
The quorum shall be two members of the Remuneration Committee, including a Lay Member in the role of Chair.
If the committee is not quorate the meeting may be postponed at the discretion of the Chair. If the meeting does take place and is not quorate, no decisions shall be made at that meeting and such matters must be deferred until the next quorate meeting (or, given the irregularity of meetings, be subject to determination by email exchange).
7. Decision-making and Voting
Generally, it is expected that meeting decisions will be reached by consensus. Should this not be possible, each voting member of the Remuneration Committee will have one vote. Decisions will be by majority vote.
In the event of a tied vote, the Chair of the committee meeting will have a second and casting vote.
Should a vote be taken, the outcome of the vote and any dissenting views will be recorded in the minutes of the meeting.
8. In Attendance
Only committee members have the right to attend committee meetings.
A representative from HR will normally be invited to attend committee meetings.
Other individuals such as the Clinical Chair or Chief Officer may be invited to attend for all or part of any meeting, as and when appropriate, however, they should not be in attendance for discussions about their own remuneration and terms of service.
9. Meetings
Meetings shall be held at least annually.
10. Sub-Committees / Groups
The Remuneration Committee may establish sub-committees or groups to support it in its role. However, they may only delegate responsibility and authority to a sub- committee or group, if legally permissible and expressly authorised to do so by the Governing Body.
11. Conduct
The Remuneration Committee will conduct its business in accordance with relevant national guidance and relevant codes of practice such as the Nolan Principles.
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12. Management of Conflicts of Interest
The Remuneration Committee will adhere to the CCG’s Business Conduct & Conflicts of Interest Policy.
If any member of the committee has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The Chair of the meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct & Conflicts of Interest Policy.
The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned:
Take part in the discussion but not in the decision-taking? Not take part in either the discussion or decision-taking? Take part in the discussion and left the meeting for the decision? or Left the meeting for the whole of the item?
In making this decision the Chair will need to consider the following points:
The nature and materiality of the decision. The nature and materiality of the declared interest(s). The availability of relevant expertise. As a general rule (and subject to the judgement of the Chair), if an interest involves a pecuniary interest or a significant non-pecuniary interest, the individual should be asked to leave the meeting for the whole item.
The Remuneration Committee will not consider remuneration matters relating to the Lay Members; these shall be considered and approved by the Governing Body (excluding the Lay Members and any other conflicted parties).
The Remuneration Committee will consider and make recommendations on the remuneration of the Professional Healthcare members of the Governing Body (the Registered Nurse and Secondary Care Consultant). The Professional Healthcare members of the committee will be excluded from these discussions due to a direct financial interest.
14. Administration
The Governance team will provide administrative support to the committee and will ensure that papers are issued at least five days before a meeting and that draft minutes are circulated within ten working days after a meeting.
The Human Resources function, in conjunction with the Governance team, will be responsible for supporting the chair in the management of the committee’s business
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and for drawing the committee’s attention to best practice, national guidance and other relevant documents as appropriate.
The Governance team in conjunction with the Human Resources function and Chair of the Remuneration Committee will develop and maintain a work programme to inform and guide the work of the committee.
15. Urgent Matters Arising Between Meetings
The Chair of the Remuneration Committee in consultation with one other remuneration committee member may also act on urgent matters arising between meetings.
These matters will be reported by email, endorsed at the next meeting of the committee and reported to the Governing Body.
16. Monitoring of Performance and Compliance
The Remuneration Committee will review its own effectiveness, its compliance with its terms of reference and the terms of reference document itself at least annually and a report of the outcomes of this review will be produced and reported to the Governing Body (or the Audit & Governance Committee on behalf of the Governing Body).
The Governing Body is responsible for monitoring the performance of the committee through receipt of its minutes and Annual Report.
17. TOR Review and Approving Body
Terms of Reference will be reviewed annually (during Quarter 1 of the year), or as and when legislation or best practice guidance is updated.
Any amended Terms of Reference will be agreed by the Remuneration Committee for recommendation for approval by a subsequent meeting of the Governing Body.
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NHS Bradford District and Craven CCG Primary Care Commissioning Committee Terms of Reference
Introduction
1. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England/Improvement has delegated the exercise of the functions specified in Schedule 2 of the Delegation Agreement to NHS Bradford District and Craven CCG.
2. The CCG has established the NHS Bradford District and Craven CCG Primary Care Commissioning Committee as a committee of the Governing Body (“Committee”). The Committee will function as a corporate decision-taking body for the management of the delegated functions and the exercise of the delegated powers.
3. It is a committee comprising representatives of NHS Bradford District & Craven CCG and attendees from the following organisations: NHS England/Improvement; Bradford District Health and Wellbeing Board; North Yorkshire Health and Wellbeing Board; Bradford and District HealthWatch; North Yorkshire HealthWatch; YOR Local Medical Committee
Statutory Framework
4. NHS England/Improvement has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 of the Delegation Agreement in accordance with section 13Z of the NHS Act.
5. Arrangements made under section 13Z will be on such terms and conditions (including terms as to payment) as is agreed between NHS
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England/Improvement and the CCG. Such arrangements are contained within the Delegation Agreement.
6. Arrangements made under section 13Z do not affect the liability of NHS England / Improvement for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including: a) Management of conflicts of interest (section 14O);
b) Duty to promote the NHS Constitution (section 14P);
c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);
d) Duty as to improvement in quality of services (section 14R);
e) Duty in relation to quality of primary medical services (section 14S);
f) Duties as to reducing inequalities (section 14T);
g) Duty to promote the involvement of each patient (section 14U);
h) Duty as to patient choice (section 14V);
i) Duty as to promoting integration (section 14Z1);
j) Public involvement and consultation (section 14Z2).
7. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those set out below:
Duty to have regard to impact on services in certain areas (section 13O); Duty as respects variation in provision of health services (section 13P).
8. The members acknowledge that the Committee is subject to any directions made by NHS England/Improvement or by the Secretary of State.
9. For the avoidance of doubt, in the event of any conflict between the terms of the Delegation Agreement, these Terms of Reference or the CCG’s Standing Orders
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or Standing Financial Instructions of the CCG, the Delegation Agreement will prevail. (See Schedule 5 of the Delegation Agreement shown at Appendix 2).
Role of the Committee
10. The Committee has been established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in the Bradford District and Craven CCG area under delegated authority from NHS England/Improvement.
11. The decisions of the Committee shall be binding on NHS England/Improvement and NHS Bradford District and Craven CCG.
12. In performing its role the Committee will exercise its management of the functions in accordance with the Delegation Agreement entered into between NHS England/Improvement and NHS Bradford District and Craven CCG.
13. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act. This includes the following:
GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);
Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);
Design of local incentive schemes in addition or as an alternative to the Quality Outcomes Framework (QOF) (such schemes shall be voluntary and the CCG will continue to offer the national scheme);
Decision making on whether to establish new GP practices in an area;
Approving practice mergers; and
Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).
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NOTE: the Finance and Performance Committee will manage and have oversight of the delegated budget for commissioning primary medical care services.
14. The CCG will also carry out the following activities:
a) To plan, including needs assessment, primary medical care services in the Bradford District and Craven CCG area;
b) To undertake reviews of primary medical care services in the Bradford District and Craven CCG area;
c) To co-ordinate a common approach to the commissioning of primary care services generally.
Membership (consisting of a majority of lay and executive members) and Attendees
15. The Committee shall consist of:
Lay and executive members: Lay member – chair Lay member – deputy chair Lay member (third lay member) Chief officer (Accountable officer) Chief finance officer Secondary care consultant or registered nurse Strategic Director for Keeping Well @ Home Strategic Director for Quality Improvement
GP members (non-voting) Clinical Chair A GP member of the Senior Leadership Team
Invited non-voting attendees: Health and Wellbeing Board representative (Bradford and North Yorkshire)
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HealthWatch representative (Bradford and North Yorkshire) YORLMC Ltd representative NHSE/I representative CCG Associate Director of Keeping Well @ Home CCG Senior Head of Strategy, Change and Delivery (Keeping Well @ Home)
16. The Chair of the Committee shall be a Governing Body lay member but not the same individual who acts as the Audit and Governance Chair.
17. The Deputy Chair of the Committee shall be a Governing Body lay member.
18. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.
Quorum
19. No business shall be transacted unless the following are present: a) The chair or deputy chair b) 50% of the voting membership of the Committee
20. Members may send deputies to represent them. Deputies will count towards quorum, but will only have voting rights if they have formal acting up status
21. If the chair of other member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of conflict of interest, that person shall no longer count towards the quorum.
Meetings and Voting
22. The Committee will operate in accordance with the CCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member and attendee no later than 4 days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.
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23. If there is an urgent need to conduct business (e.g. where there is a requirement to take contractual action such as issuing a breach or remedial action notice) the chair will call a meeting of the committee to a timescale commensurate with the response required. Alternatively the chair may elect to convene a virtual meeting, via e-mail or teleconference.
24. The aim of the Committee will be to achieve decision-making by consensus. Should this not be possible, each member of the Committee shall have one vote (with the exception of the GPs and any other conflicted members). The Committee shall reach decisions by a simple majority of members present, with the Chair having a second and deciding vote, if necessary. Should a vote be taken, the outcome of the vote and any dissenting views will be recorded in the minutes.
Management of Conflicts of Interest
25. The PCCC will adhere to the CCG’s Business Conduct & Conflicts of Interest Policy.
26. If any member of the PCCC has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The Chair of the meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct & Conflicts of Interest Policy.
27. The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned: Take part in the discussion but not in the decision-taking Not take part in either the discussion or decision-taking Take part in the discussion and left the meeting for the decision or Left the meeting for the whole of the item
28. In making this decision the Chair will need to consider the following points: the nature and materiality of the decision the nature and materiality of the declared interest(s)
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the availability of relevant expertise as a general rule (and subject to the judgement of the Chair), if an interest involves a financial interest or a significant non-financial interest, the individual should be asked to leave the meeting for the whole item
Frequency and conduct of meetings
29. Meetings shall take place no less than every two months or more frequently as required by the volume and/or urgency of business to be transacted.
30. Meetings of the Committee shall:
a) be held in public, subject to the application of 30(b);
b) the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.
31. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.
Sub-Groups
32. The PCCC may establish sub-committees or groups to support it in its role. However, they may not delegate responsibility and authority to a sub-committee or group without express authorisation via an amendment to these terms of reference.
33. The PCCC has established a sub-group, the Contracts Assurance Group (CAG) to support the committee in fulfilling the terms of the Delegation Agreement. The
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PCCC approves and keeps under review the terms of reference of CAG (available on the CCG website). A report on the work of and any recommendations made by CAG is presented to each meeting of the PCCC via the Contract Assurance and Performance Report.
34. The CAG has no decision-taking authority. Where appropriate, and as set out in CAG’s terms of reference, the group will make recommendations to the PCCC. All decision-taking authority lies with the PCCC.
Reporting and Review
35. The Committee will present its minutes to NHS England/Improvement and the Governing Body of NHS Bradford District and Craven CCG every two months for information.
36. The terms of reference of the PCCC will be reviewed on at least an annual basis (during Quarter 1 of the year) and recommended for approval by a subsequent meeting of the Governing Body. NHS England/Improvement may also issue revised model terms of reference from time to time.
37. The PCCC will present an annual report of its work to the Governing Body via the CCG’s Annual Report. As required by CCG Annual Report guidance this will include, as a minimum, information relating to: key responsibilities, membership, attendance records and highlights of the Committee’s work during the year.
38. The PCCC will review its own effectiveness on a regular basis. A report of the outcomes of this review will be produced and reported to the PCCC and also to the Audit & Governance Committee on behalf of the Governing Body.
Schedule 1 – Please refer to the Delegation Agreement dated 9th March 2020. The summary version of the Delegation Agreement is included at Appendix A].
Schedule 2 – Please refer to Schedule 2 (Parts 1 and 2) of the Delegation Agreement for a description of the delegated functions Schedule 5 Financial Provisions and Decision Making Limits – please see Schedule 5 Table 1 of the delegation (Appendix B).
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Appendix A – Summary Delegation Agreement
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Appendix B - Schedule 5 of the Delegation Agreement
Financial Provisions and Decision Making Limits
Financial Limits and Approvals
1. The CCG shall ensure that any decisions in respect of the Delegated Functions and which exceed the financial limits set out below are only taken:
1.1. by the following persons and/or individuals set out in column 2 of Table 1 below; and 1.2. following the approval of NHS England (if any) as set out in column 3 of the Table 1 below.
2. NHS England may, from time to time, update Table 1 by sending a notice to the CCG of amendments to Table 1.
Table 1 – Financial Limits
Decision Person/Individual NHS England Approval
General
Taking any step or action in CCG Chief Officer or Chief NHS England Head of Legal relation to the settlement of a Finance Officer or Chair Services Claim, where the value of the and settlement exceeds £100,000 Local NHS England Team Director or Director of Finance
Any matter in relation to the CCG Chief Officer or Chief Local NHS England Team Delegated Functions which is Finance Officer or Chair Director or Director of Finance novel, contentious or or repercussive NHS England Region Director or Director of Finance or
NHS England Chief Executive or Chief Financial Officer
Revenue Contracts
The entering into of any CCG Chief Officer or Chief Local NHS England Team Primary Medical Services Finance Officer or Chair Director or Director of Finance Contract which has or is capable of having a term which exceeds five (5) years
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Capital:
As at the date of this Agreement, the CCG will not have delegated or directed responsibility for decisions in relation to Capital expenditure (and these decisions are retained by NHS England) but the CCG may be required to carry out certain administrative services in relation to Capital expenditure under clause 13 (Financial Provisions and Liability).
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Appendix 3: Standing Orders 1. STATUTORY FRAMEWORK AND STATUS
1.1. Introduction
1.1.1. These standing orders have been drawn up to regulate the proceedings of the NHS Bradford District and Craven Clinical Commissioning Group so that the CCG can fulfil its obligations, as set out largely in the 2006 Act, as amended by the 2012 Act and related regulations . They are effective from the date the constitution is approved by NHS England
1.1.2. The standing orders, together with the CCG’s scheme of reservation and delegation2 and the CCG’s standing financial instructions3, provide a procedural framework within which the CCG discharges its business. They set out:
a) the arrangements for conducting the business of the CCG
b) the arrangements for making appointments to the Governing Body and various CCG and Governing Body Committees
c) the procedure to be followed at meetings of the CCG, the Governing Body and any committees or sub-committees of the CCG or the Governing Body
d) the process to delegate powers
e) the declaration of interests and standards of conduct.
These arrangements must comply, and be consistent where applicable, with requirements set out in the 2006 Act (as amended by the 2012 Act) and related regulations and take account as appropriate4 of any relevant guidance.
1.1.3. CCG members, employees, members of the Governing Body, members of the Governing Body’s committees and sub-committees, members of the CCG’s committees and sub-committees and persons working on behalf of the CCG should be aware of the existence of the documents referred to in paragraph 1.1.2 above and, where necessary, be familiar with their detailed provisions. Failure to comply with the standing orders, scheme of
2 Available on the CCG website www.bradfordcravenccg.nhs.uk 3 Available on the CCG website www.bradfordcravenccg.nhs.uk 4 Under some legislative provisions the group is obliged to have regard to particular guidance but under other circumstances guidance is issued as best practice guidance.
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reservation and delegation and standing financial instructions may be regarded as a disciplinary matter that could result in dismissal.
1.2. Schedule of matters reserved to the clinical commissioning group and the scheme of reservation and delegation
1.2.1. The 2006 Act (as amended by the 2012 Act) provides the CCG with powers to delegate the CCG’s functions and those of the Governing Body to certain bodies (such as committees) and certain persons. The CCG has decided that certain decisions may only be exercised by (are reserved to) the members of the CCG. These decisions and also those delegated are contained in the CCG’s scheme of reservation and delegation which is available here. www.bradfordcravenccg.nhs.uk
2. THE CLINICAL COMMISSIONING GROUP: COMPOSITION OF MEMBERSHIP, KEY ROLES AND APPOINTMENT PROCESS
2.1. Composition of membership
2.1.1. Section 3.1 of the CCG’s constitution provides details of the membership of the CCG.
2.2. Key Roles
2.2.1. The NHS Commissioning Board in clinical commissioning group governing body members: role outlines, attributes and skills (October 2012) https://www.england.nhs.uk/wp-content/uploads/2016/09/ccg- members-roles.pdf and subsequent guidance has been used as the basis for the preparation of role descriptions and person specifications for appointment to key roles on the Governing Body and the Senior Leadership Team. Such appointments will be subject to a requirement to meet eligibility criteria and are not disqualified for membership as specified in The National Health Service (Clinical Commissioning Groups) Regulations 2012 [‘the NHS Regulations’] and subsequent legislation.
2.2.2. Terms of office for GP members of the Senior Leadership Team and non- employee members of the Governing Body:
a) GP members of the Senior Leadership Team and non-employee members of the Governing Body will normally be re-elected or re- appointed at least every three years b) no one individual can serve longer than three full terms (i.e. nine years), save in exceptional circumstances determined by the CCG Council and Governing Body.
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c) one-third of GP members of the Senior Leadership Team and non- employee members of the Governing Body may be appointed for between two and five years to allow for continuity/succession planning. d) where the tenure of positions within the Governing Body and of lay members was due to end in March 2021 we have rolled over the tenure of these posts for a further 12 months to March 2022.
2.2.3. The GP members of the Senior Leadership Team (strategic clinical directors) are subject to the following appointment process:
a) Nominations – when a position is or is about to become vacant this shall be declared to member practices. GPs should express an interest to the CCG officer responsible for overseeing the election process
b) Eligibility – candidates will be GPs (non-principal, salaried or partner) who work the majority of their clinical time (expected to be at least 50 sessions per annum) in one or more of the CCG’s member practices. They will be able to demonstrate the attributes and skills required by the CCG. They will meet the eligibility criteria and not be excluded from governing body membership as laid down in the NHS Regulations. The LMC will be involved in the assessment of eligibility of candidates. The process for assessing the eligibility (including competency) of candidates will determined by the Chief Officer and approved by the CCG Council
c) Appointment process –following confirmation of eligibility, election by all GPs (non-principal, salaried or partner) practising in the CCG’s member practices. Where more than one nominated and eligible GP is identified for a role, an election will take place. This will be on the basis of one GP, one vote. The election will be administered by the LMC.
d) Term of office – see section 2.2.2 above
e) Eligibility for reappointment – following initial election and the first term of office, an elected GP will be eligible for reappointment by the clinical chair for a second term of office (up to a maximum of six years from the initial election unless otherwise agreed by the CCG Council) provided he/she continues to meet the appointment criteria and subject to satisfactory performance appraisal.
f) Grounds for removal from office – the GP Senior Leadership Team member will be removed from office if that person:
i. receives a 75% vote of no confidence at a meeting of the CCG Council duly convened (see section 2.2.15)
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ii. ceases to be a practitioner (minimum of 50 sessions per annum) in a CCG member practice(s) iii. is removed from the List of Registered Medical Practitioners (the List) or removed temporarily if suspended from the List pending a hearing iv. become disqualified from governing body membership under the NHS Regulations v. resigns as a Senior Leadership Team member and such resignation has taken effect in accordance with its terms
g) Notice period – the elected GPs shall give 3 months written notice of their intention to resign to the chair.
Up to six GPs will be elected to the Senior Leadership Team of the CCG. Of the elected GPs, two will be appointed to the Governing Body, including one to the role of clinical chair.
2.2.4. The role of Chief Clinical Information Officer is not subject to section 2.2.2/3 above but is a substantive appointment governed by the HR processes for staff members of the CCG (see section 2.2.14 below).
2.2.5. The Clinical Chair who is chair of the CCG and the Governing Body and the co-chair of the Senior Leadership Team is subject to the following appointment process:
a) Nominations – a GP Senior Leadership Team member interested in applying for this role when it is vacant or about to become vacant should express interest to the CCG officer overseeing the appointment process
b) Eligibility – candidates shall be a GP member of the Senior Leadership Team, appointed by the membership. They will be able to demonstrate attributes and skills outlined in guidance and as required by the CCG. They will meet the eligibility criteria and not be excluded from governing body membership as laid down in the NHS Regulations. The process for assessing the eligibility (including competency) of candidates will determined by the Chief Officer and approved by the CCG Council. The LMC will be involved in the assessment of eligibility of candidates.
c) Appointment process – the appointment process will be determined by the Chief Officer and approved by the CCG Council.
d) Term of office – see section 2.2.2 above.
e) Eligibility for reappointment– following initial election and the first term of office, the Clinical Chair will be eligible for reappointment by the Chair of the CCG Council for a second term of office (up to a
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maximum of six years from the initial election, unless otherwise agreed by the CCG Council) provided he/she continues to meet the appointment criteria and subject to satisfactory performance appraisal. The Clinical Chair’s appraisal will be undertaken jointly by the chair of the CCG Council and the Senior Independent Director with input from members of the Governing Body and Senior Leadership Team.
f) Grounds for removal from office – the Clinical Chair will be removed from office if that person:
i. receives a 75% majority vote of no confidence at a meeting of the CCG Council duly convened (see section 2.2.15); ii. ceases to be a practitioner (minimum of 50 sessions per annum) in a CCG member practice(s); iii. is removed from the List of Registered Medical Practitioners (the List) or removed temporarily if suspended from the List pending a hearing; iv. become disqualified from governing body membership under the NHS Regulations; v. resigns as a Senior Leadership Team member and such resignation has taken effect in accordance with its terms.
g) Notice period – the Clinical Chair shall give 3 months written notice of their intention to resign to the Chief Officer and Chair of the CCG Council.
2.2.6. The Deputy Chair (who is Deputy Chair of the CCG and of the Governing Body) is subject to the following appointment process:
a) Nominations – not applicable; the deputy chair shall be selected by the Clinical Chair from one of the lay members (this shall not be the same Lay Member who chairs the Audit & Governance Committee).
b) Eligibility – only lay members are eligible for appointment as Deputy Chair.
c) Appointment process – the Deputy Chair shall be selected by the Clinical Chair.
d) Term of office – see section 2.2.2 above; any appointment as Deputy Chair will run in parallel with the lay member appointment.
e) Eligibility for reappointment – the Deputy Chair will be eligible for reappointment provided he/she continues to meet the appointment criteria and is subject to satisfactory performance appraisal. A lay member cannot be appointed to the same role for more than three terms of office.
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f) Grounds for removal from office - a lay member will be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
2.2.7. The Senior Independent Director will be available (i) where concerns relating to CCG business are raised and are not able to be resolved through the usual channels and (ii) to support the Clinical Chair in leading the Governing Body, and is subject to the following appointment process:
a) Nominations – not applicable; the Senior Independent Director shall be selected by the Clinical Chair in consultation with the Chair of the CCG Council, from one of the lay members.
b) Eligibility – only lay members are eligible for appointment as the Senior Independent Director.
c) Appointment process – the Senior Independent Director shall be selected by the Clinical Chair in consultation with the Chair of the CCG Council.
d) Term of office – see section 2.2.2 above; any appointment as Senior Independent Director will run in parallel with the lay member appointment.
e) Eligibility for reappointment – the Senior Independent Director will be eligible for reappointment provided he/she continues to meet the appointment criteria and is subject to satisfactory performance appraisal. A lay member cannot be appointed to the same role for more than three terms of office.
f) Grounds for removal from office - a lay member will be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
2.2.8. The Deputy Clinical Chair, who deputises for the Clinical Chair on clinical matters, will be a Strategic Clinical Director and member of the Senior Leadership Team and is subject to the following appointment process:
a) Nominations – not applicable; the Deputy Clinical Chair shall be selected by the Clinical Chair from one of theGP members of the Senior Leadership Team..
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b) Eligibility – only GP members of the Senior Leadership Team are eligible to act as Deputy Clinical Chair.
c) Appointment process – the Deputy Clinical Chair shall be selected by the Clinical Chair from one of the GP members of the Senior Leadership Team.
d) Term of office – see section 2.2.2 above; any appointment as Deputy Clinical Chair will run in parallel with appointment as a GP member of the Senior Leadership Team
e) Eligibility for reappointment – the Deputy Clinical Chair will be eligible for reappointment by the Clinical Chair provided he/she continues to meet the appointment criteria and is subject to satisfactory performance appraisal.
f) Grounds for removal from office – the Deputy Clinical Chair will be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
NOTE: the Deputy Clinical Chair deputises for the Clinical Chair at Senior Leadership Team meetings and on clinical matters only. The Deputy Chair of the CCG and of the Governing Body will be a lay member (see section 2.2.6).
2.2.9. The GP Senior Leadership Team member of the Governing Body (if not the same individual who undertakes the role of Deputy Clinical Chair, see section 2.2.8 above) is subject to the following appointment process:
a) Nominations – not applicable; the GP Senior Leadership Team member of the Governing Body shall be selected by the Clinical Chair from one of the GP members of the Senior Leadership Team.
b) Eligibility – being an elected GP member of the Senior Leadership Team (see section 2.2.4) they will be able to demonstrate attributes and skills outlined in guidance and not be excluded from governing body membership as laid down in the NHS Regulations
c) Appointment process – the Clinical Chair will determine which of the elected GPs on the Senior Leadership Team shall act as the GP Senior Leadership Team member of the Governing Body
d) Term of office – as determined by the Clinical Chair and subject to the provisions of section 2.2.3
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e) Grounds for removal from office – the GP Senior Leadership Team member of the Governing Body will be removed from office if that person:
i. receives a 75% majority vote of no confidence at a meeting of the CCG Council duly convened (see section 2.2.15) ii. ceases to be a practitioner (minimum of 50 sessions per annum) in a CCG member practice iii. is removed from the List of Registered Medical Practitioners (the List) or removed temporarily if suspended from the List pending a hearing iv. become disqualified from governing body membership under the NHS Regulations v. resigns as a member of the Senior Leadership Team and such resignation has taken effect in accordance with its terms.
f) Notice period – the GP Senior Leadership Team member of the Governing Body shall give three months written notice of their intention to resign to the Clinical Chair.
2.2.10. The Lay Members, the Registered Nurse and the Secondary Care Consultant are subject to the following appointment process:
a) Nominations – individuals interested in applying for vacant positions as a Lay Member, the Registered Nurse or the Secondary Care Consultant on the Governing Body shall answer advertisements for these positions
b) Eligibility – candidates should demonstrate that they possess the relevant skills and experience which would enhance the Governing Body’s effectiveness and decision making and be able to hold to account the clinicians and officers of the CCG. They will be able to demonstrate attributes and skills outlined in guidance. They will meet the eligibility criteria and not be excluded from governing body membership as laid down in the NHS Regulations
c) Appointment process – the selection and appointment process will be determined by the Clinical Chair and approved by the CCG Council
d) Term of office – see section 2.2.2 above
e) Eligibility for reappointment – individuals will be eligible for reappointment by the Clinical Chair provided he/she continues to meet the appointment criteria and is subject to satisfactory performance appraisal. A Lay Member / Registered Nurse / Secondary Care Consultant cannot be appointed to the same role for more than three terms of office
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f) Grounds for removal from office:
A Lay Member will be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
The Registered Nurse will be removed from office in the event that they are removed from the NMC register or removed temporarily if they are suspended from the register pending a hearing. They shall be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
The Secondary Care Consultant will be immediately removed from office in the event that they are removed from the GMC Specialist Register and are no longer eligible to be included or removed temporarily if they are suspended from the register pending a hearing. They shall be removed from office if they no longer meet the eligibility requirements, become disqualified under NHS Regulations or should there be a 75% majority no confidence vote in that individual at a meeting of the CCG Council (see section 2.2.15).
g) Notice period – the Lay Members, Registered Nurse and Secondary Care Consultant shall give three months written notice of their intention to resign to the clinical chair.
2.2.11. The Accountable Officer (who will be known as the Chief Officer) is subject to the following appointment process:
a) Nominations - candidates shall be able to apply for this role as advertised by the CCG.
b) Eligibility – candidates will be able to demonstrate the experience, attributes and skills outlined in guidance. They will meet the eligibility criteria and not be excluded from governing body membership as laid down in the NHS Regulations.
c) Appointment process – the selection and nomination process will be determined by the Clinical Chair, in consultation with NHS England and approved by the CCG Council. The interview panel will include an external individual capable of providing an expert opinion on the candidate’s ability to undertake the role. The interview panel will nominate an applicant to NHS England and the applicant must receive positive confirmation that they meet the requirements for appointment as set out by NHS England. The Chief Executive of
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NHS England is legally responsible for confirming accountable officer status on the successful applicant.
d) Term of office – the Chief Officer will serve for the duration of their employment.
e) Grounds for removal from office – an individual will cease to be the Chief Officer if:
i. their employment is terminated in accordance with his/her contract of employment (see also section 2.2.16) ii. they become a disqualified person under NHS Regulations.
f) Notice period – the Chief Officer shall give six months’ written notice to the clinical chair.
2.2.12. The Chief Finance Officer is subject to the following appointment process:
a) Nominations – candidates shall be able to apply for this role as advertised by the CCG.
b) Eligibility – candidates will be able to demonstrate attributes and skills outlined in guidance. They will meet the eligibility criteria and not be excluded from governing body membership as laid down in the NHS Regulations.
c) Appointment process – the selection and appointment process will be determined by the Chief Officer and approved by the CCG Council.
d) Term of office – the Chief Finance Officer will serve for the duration of their employment.
e) Grounds for removal from office – the Chief Finance Officer will cease to be a member of the Governing Body if:
i. their employment is terminated in accordance with his/her contract of employment (see also section 2.2.16) ii. they become a disqualified person under NHS Regulations.
f) Notice period – the Chief Finance Officer shall give six months’ written notice of their intention to resign to the Chief Officer.
2.2.13. The additional managerial member of the Governing Body, who will be a managerial member of the Senior Leadership Team is subject to the following appointment process:
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a) Nominations – not applicable; the additional managerial member of the Governing Body will be selected by the Chief Officer from one of the managerial members of the Senior Leadership Team.
b) Eligibility – only managerial members of the Senior Leadership Team are eligible to act in this role.
c) Appointment process – the additional managerial member of the Governing Body will be selected by the Chief Officer from one of the managerial members of the Senior Leadership Team.
d) Term of office – to be agreed by the Chief Officer upon appointment to the Governing Body and as set out in the letter of appointment.
e) Grounds for removal from office – the managerial member will cease to be a member of the Governing Body if:
i. their employment is terminated in accordance with his/her contract of employment (see also section 2.2.16) ii. they become a disqualified person under NHS Regulations.
f) Notice period – the managerial member of the Governing Body shall give six months’ written notice of their intention to resign to the Clinical Chair.
2.2.14. The managerial members of the Senior Leadership Team (strategic directors) and the Chief Clinical Information Officer (CCIO) are subject to the following appointment process:
g) Nominations – candidates shall be able to apply for this role as advertised by the CCG.
h) Eligibility – candidates will be able to demonstrate attributes and skills outlined in guidance; for the CCIO role, candidates will be a healthcare professional.
i) Appointment process – the selection and appointment process will be determined by the Chief Officer.
j) Term of office – managerial members of the Senior Leadership Team and the Chief Clinical Information Officer will serve for the duration of their employment.
k) Grounds for removal from office – a managerial member or the CCIO will cease to be a member of the Senior Leadership Team if their contract of employment is terminated in accordance with his / her contract of employment (see also section 2.2.16).
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l) Notice period – the managerial members of the Senior Leadership Team shall give three months’ written notice of their intention to resign to the Chief Officer.
2.2.15. In the event that member practices express a loss of confidence in a non- employee member of the Senior Leadership Team or Governing Body, an extraordinary general meeting may be called by at least 60% of the member practices and a vote of at least 75% of member practices present at the meeting will be required in order to remove that individual from office.
2.2.16. In the event that member practices express a loss of confidence in a member/s of the Senior Leadership Team or Governing Body who has employee status, an extraordinary general meeting may be called by at least 60% of the member practices, and a vote of at least 75% of member practices present at the meeting will be required in order to refer the concerns of the member practices to the clinical chair. The clinical chair will deal with the matter in line with the CCG’s HR policies and procedures.
3. MEETINGS OF THE CLINICAL COMMISSIONING GROUP
3.1. Calling meetings
3.1.1. The Governing Body will meet no less than four times per annum. The CCG Council shall meet at least two times per annum, including an annual meeting with the members of the Governing Body and Senior Leadership Team at which the CCG’s accounts and annual report are received. The frequency of meetings of committees of the CCG and committees of the Governing Body are set out in their terms of reference available on the CCG website www.bradfordcravenccg.nhs.uk.
3.1.2. The clinical chair on receiving a request from four or more of the membership of the Governing Body to call an extraordinary meeting of the Governing Body, shall issue a notice for the meeting within 5 working days of being requested to do so.
3.1.3. An extraordinary meeting of the CCG Council can be called by at least 60% of member practices submitting such a request to the chair of the CCG Council; at least 10 working days’ notice will be given of such a meeting.
3.1.4. Notice of any meeting of the Governing Body or CCG Council must indicate:
a) its proposed date and time, which must be at least five working days after the date of the notice for the Governing Body and 10 working days for the CCG Council, except where a meeting to discuss an
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urgent issue is required (in which case as much notice as reasonably practicable in the circumstances should be given) b) where it is to take place c) an agenda of the items to be discussed at the meeting d) any supporting papers will be made available within at least four working days of the meeting.
3.1.5. Notice of a Governing Body or CCG Council meeting must be given to each relevant member in writing (which shall include email).
3.1.6. Failure to effectively serve notice on all Governing Body or CCG members does not affect the validity of the meeting, or of any business conducted at it.
The frequency of meeting of committees of the CCG and committees of the Governing Body are set out in their terms of reference which are all available via the CCG website www.bradfordcravenccg.nhs.uk. The terms of reference of some committees are also set out at Appendix 2 of this constitution.
3.2. Agenda, supporting papers and business to be transacted
3.2.1. Items of business to be transacted for inclusion on the agenda of a meeting need to be notified to the chair of the meeting at least seven working days (i.e. excluding weekends and bank holidays) before the meeting takes place. Supporting papers for such items need to be submitted at least five working days before the meeting takes place. The agenda and supporting papers will be circulated to all members of a meeting at least four working days before the date the meeting will take place.
3.2.2. Agendas and public papers for the CCG’s Governing Body and the CCG’s Primary Care Commissioning Committee – including details about meeting dates, times and venues - will be published on the CCG’s website at www.bradfordcravenccg.nhs.uk Paper copies of the agenda and certain papers will also be made available at meetings of the Governing Body and Primary Care Commissioning Committee. Paper copies are also available upon request or upon application by post to Scorex House, 1 Bolton Road, Bradford, BD1 4AS or e-mail to [email protected].
3.3. Petitions
3.3.1. Where a petition has been received by the CCG, the Clinical Chair shall include the petition as an item for the agenda of the next meeting of the Governing Body.
3.4. Chair of a meeting
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3.4.1. At any meeting of the CCG or its Governing Body or of a committee or sub-committee, the Chair of the CCG, Governing Body, committee or sub- committee, if any and if present, shall preside. If the Chair is absent from the meeting, the Deputy Chair, if any and if present, shall preside.
3.4.2. If the Chair is absent temporarily on the grounds of a declared conflict of interest the Deputy Chair, if present, shall preside. If both the Chair and Deputy Chair are absent, or are disqualified from participating, or there is neither a Chair or Deputy a member of the CCG, Governing Body, committee or sub-committee respectively shall be chosen by the members present, or by a majority of them, and shall preside.
3.4.3. Where the Governing Body or any committees of the Governing Body or of the CCG holding meetings in common with other CCGs, a ‘meeting chair’ shall be appointed purely for the purposes of administering the meeting; the chair of each CCG retains their authority under Section 3.5.1 below.
3.5. Chair's ruling
3.5.1. The decision of the chair of any meeting of the CCG Council, Governing Body or in a committee setting on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and standing financial instructions at the meeting, shall be final.
3.6. Quorum
3.6.1. No business shall be transacted at a Governing Body meeting unless the following are present:
a) the Chair or Deputy Chair b) 50% of the membership
Attendance via telephone or video link is deemed to count towards quorum.
Members may send deputies to represent them at Governing Body meetings with the agreement of the chair. Deputies will count towards quorum but will only have voting rights if they have formal acting up status.
3.6.2. No business shall be transacted at a meeting of the CCG Council unless the following are present:
a) the Chair (or member practice representative nominated by the Chair to act in their absence) b) 50% of member practices
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3.6.3. If the Chair or other member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest, that person shall no longer count towards the quorum for that agenda item.
3.6.4. Quorum arrangements for committees of the CCG and committees of the Governing Body are set out in their terms of reference which are all available via the CCG website www.bradfordcravenccg.nhs.uk. The terms of reference of some committees are also set out at Appendix 2 of this constitution.
3.7. Decision taking
3.7.1. Generally it is expected that at meetings of the CCG Council, Governing Body and all committees and sub-committees that decisions will be reached by consensus. Should this not be possible then a vote of members will be required, the process for which is set out below:
a) eligibility – all members (or those deputising for members with formal acting up status) shall have a single vote
b) majority necessary to confirm a decision – simple majority of those present (present includes those attending via telephone or video link)
c) casting vote – the chair of the meeting.
3.7.2. Should a vote be taken the outcome of the vote, and any dissenting views, must be recorded in the minutes of the meeting.
3.8. Emergency powers and urgent decisions
3.8.1. It is recognised that there will be times when urgent decisions are required. The Clinical Chair, the Chief Officer and Chief Finance Officer have the authority individually to define an urgent decision on behalf of the Governing Body.
3.8.2. The Clinical Chair, Chief Officer and Chief Finance Officer have the authority individually to make an urgent decision without consultation with the Governing Body, although where possible, efforts must be made to contact and consult with the Governing Body before taking such decisions. Where possible, they will always discuss urgent decisions with others who have this equal authority.
3.8.3. Such decisions will be reported to the next Governing Body meeting. To ensure that any urgent decisions taken are examined and the principles of good governance are upheld, a report will be submitted detailing:
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a) the grounds on which it was decided to take the decision on an urgent basis b) the efforts made to contact the other members of the Governing Body prior to taking the decision.
3.8.4. The Chair of the CCG Council, in consultation with the Clinical Chair or Chief Officer, may act on urgent matters of CCG Council business arising between meetings. Where an urgent decision has been taken, this will be notified to CCG Council members by email. A formal report will then be taken to the next meeting of the CCG Council, where the Chair of the Council will explain the reason for the action taken.
3.8.5. Arrangements for taking urgent decisions for committees of the CCG and committees of the Governing Body are set out in their terms of reference which are all available via the CCG website www.bradfordcravenccg.nhs.uk. The terms of reference of some committees are also set out at Appendix 2 of this constitution.
3.9. Suspension of Standing Orders
3.9.1. Except where it would contravene any statutory provision or any direction made by the Secretary of State for Health or NHS England, any part of these standing orders may be suspended at any meeting, provided two- thirds of members present are in agreement.
3.9.2. A decision to suspend standing orders together with the reasons for doing so shall be recorded in the minutes of the meeting.
3.9.3. A separate record of matters discussed during the suspension shall be kept. These records shall be made available to the audit and governance committee for review of the reasonableness of the decision to suspend standing orders.
3.10. Record of Attendance
3.10.1. The names of all members and attendees present at any meeting shall be recorded in the minutes of the meetings.
3.11. Minutes
3.11.1. The minutes of the proceedings of a meeting will be confirmed as a true record through formal acknowledgement at the next meeting.
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3.11.2. Attendees and apologies will be recorded in the minutes.
3.11.3. No discussion shall take place upon the minutes except upon their accuracy or where the chair considers discussion appropriate.
3.11.4. Minutes shall be sent to meeting members. Minutes of meetings held in public (public sections of Governing Body and Primary Care Commissioning Committee meetings) will be made public via the CCG’s website www.bradfordcravenccg.nhs.uk
3.11.5. Administrative support will be made available to take and draft minutes.
3.12. Admission of public and the press
3.12.1. Admission and exclusion of the public and press at CCG meetings is based on grounds of confidentiality of the business to be transacted.
3.12.2. The CCG has agreed criteria for exclusion of business from the public part of Governing Body and Primary Care Commissioning Committee meetings and these are set out below. The application of the criteria is always subject to a public interest test.
Information relating to any individual. Information which is likely to reveal the identity of an individual. Information relating to the financial or business affairs of any particular person (including the authority holding that information). Information relating to any consultations or negotiations, or contemplated consultations or negotiations, in connection with any labour relations matter. Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings. Information relating to any action taken or to be taken in connection with the prevention, investigation or prosecution of crime.
3.12.3. The public and representatives of the press may attend any public meeting of the Governing Body or the Primary Care Commissioning Committee and should only be required to withdraw from these meetings where any information being shared is exempt from publication under the agreed criteria.
3.12.4. The public and representatives of the press shall be required to withdraw from the meeting upon a resolution as follows:
“That representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the
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confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest” Section 1 (2), Public Bodies (Admission to Meetings) Act 1960
3.12.5. A meeting can consider an emergency resolution to exclude the public/press, or to adjourn to a private place if any of those present are disrupting its business and will not leave on request.
3.12.6. When the public/press are excluded, members and other invited attendees will be required not to disclose the contents of papers or discussions without the express permission of the clinical chair or the chair of the Primary Care Commissioning Committee. The discussion can identify a future point at which the contents are no longer confidential and the minutes shall record this.
4. COMMITTEES AND SUB-COMMITTEES
4.1. Establishment of and delegation to committees and sub-committees
4.1.1. As set out in sections 4.3 – 4.4 of the constitution, the CCG Council may establish committees and sub-committees of the CCG and the Governing Body may establish committees and sub-committees of the Governing Body,
4.1.2. Committees are authorised to create sub-committees or working groups as necessary to fulfil their responsibilities as set out in their terms of reference. However, committees may not executive delegate powers delegated to them, unless expressly authorised to do so via approval of an amendment to their terms of reference.
4.2. Appointment to committees and sub-committees
4.2.1. Other than where there are statutory requirements relating to membership, such as in relation to the audit and governance committee, the remuneration committee and the Primary Care Commissioning Committee, each committee or sub-committee shall determine its own membership subject to agreement of its terms of reference by the body to which it is accountable.
4.3. Terms of Reference
4.3.1. Terms of reference shall be made available on the CCG website www.bradfordcravenccg.nhs.uk. Where there is a requirement to do so, terms of reference are also included at Appendix 2 of this constitution.
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5. DUTY TO REPORT NON-COMPLIANCE WITH STANDING ORDERS AND STANDING FINANCIAL INSTRUCTIONS
5.1. If for any reason these standing orders or the CCG’s standing financial instructions (available here www.bradfordcravenccg.nhs.uk) are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the audit and governance committee and where appropriate to the next formal meeting of the Governing Body for action or ratification. All members of the CCG and staff have a duty to disclose any non-compliance with these standing orders to the Chief Officer as soon as possible.
6. USE OF SEAL AND AUTHORISATION OF DOCUMENTS
6.1. Clinical Commissioning Group’s seal
6.1.1. The CCG may have a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature:
a) the Clinical Chair b) the Chief Officer c) the Chief Finance Officer.
6.2. Execution of a document by signature
6.2.1. The following individuals are authorised to execute a document on behalf of the CCG by their signature:
a) the Clinical Chair b) the Chief Officer c) the Chief Finance Officer.
7. OVERLAP WITH OTHER CLINICAL COMMISSIONING GROUP POLICIES AND PROCEDURES
7.1. Policy statements: general principles
Policies / procedures which will apply to all or specific groups of staff employed by the CCG will be agreed and approved in line with the CCG’s policy for the development and management of policies, procedures and guidance documents .
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The decisions to approve such policies and procedures will be recorded in the minutes of the relevant meeting.
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323 APPENDIX 4 FINANCIAL SCHEME OF DELEGATION
Appendix 4: Financial Scheme of Delegation
Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
1. Bank Accounts
Maintenance and operation in accordance with mandate approved by the Governing Body Chief Finance Officer
Day to day operation of organisation’s Bank Accounts Senior Finance Manager (Corporate)
Authorisation for Cash Limit Drawdown Strategic Head of Finance
2. Budget Management
Responsibility for maintaining expenditure within budgets: Limits are set per transaction
a) For designated budgets (pay and non pay) a. Budget holder
b) Reserves b. Chief Finance Officer
c) At Clinical Commissioning Group level. c. Chief Finance Officer or Chief Officer
Transaction limits are: Up to £5,000 Budget Holder Up to £30,000 Senior Head of Strategy, Change and Delivery Up to £50,000 Associate Director Up to £250,000 Strategic Director Over £250,000 Chief Finance Officer / Chief Officer
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
Approval of the CCG financial plan. Governing Body
Approval of variations to the approved budget where variation would have a significant impact on the Governing Body overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims.
3. Budget Virement
Budget virement is the process of transferring financial resources either within a single budget, or between different budgets. Budget virement limits are:
a) Budget Holder a) Up to the lower of the available budget and £50,000.
b) Chief Finance Officer / Chief Officer b) Over £50,000.
To effect a budget virement over £50,000, a budget virement form must be completed and authorised by the CFO. Virements between non pay and pay are subject to the establishment control process.
4. Existing Contracts / Agreements - Purchase of Healthcare from NHS and Non-NHS Bodies (including Foundation Trusts, Private Providers, Charities and Independent Contractors).
Signing of Annual Contracts / Service Level Agreements: a) Up to £50,000 a) Associate Director
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available) b) Up to £250,000 b) Strategic Director c) Over £250,000 c) Chief Officer or Chief Finance Officer
In-year contract variations with no financial implications Associate Director
Approval of Invoices for Agreed Contracts (subject to exceptions noted below): a) Up to £5,000 a) Budget Holder b) Up to £30,000 b) Senior Head of Strategy, Change and Delivery c) Up to £50,000 c) Associate Director d) Up to £250,000 d) Strategic Director e) Over £250,000 e) Chief Finance Officer or Chief Officer
Exception 1
Commissioning and Healthcare Contract Invoices: Invoices under SLA, Contracts with Foundation Trusts or partnership agreements with Local Authorities or Collaborative Arrangements with other CCGs where the SLA/Contract has been formally agreed: a) Up to £25,000,000 a) Associate Director / Strategic Head of
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
Finance b) Over £25,000,000 b) Chief Finance Officer or Chief Officer Exception 2
Continuing Healthcare, Personal Health Budget and Funded Nursing Care Invoices where care package has been agreed: a) Head of PCD a) Up to £50,000 b) Associate Director of Quality and Nursing b) Up to £500,000 c) Strategic Director of Quality and Nursing c) Up to £5,000,000 d) Chief Finance Officer or Chief Officer d) Over £5,000,000
Authorisation of Non-Invoice payments and urgent payments on Oracle following approval as above. Strategic Head of Finance, Senior Finance Manager (Corporate)
5. Non-Contracted Healthcare Activity Invoices
Invoice approval limits are: a) Head of Strategy, Change and Delivery a) Up to £10,000 b) Senior Head of Strategy, Change and b) Up to £30,000 Delivery
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
c) Over £30,000 c) Associate Director
6. New Expenditure (whole life costs).
Business Cases
The threshold for all new contracts (NHS and Non-NHS) which require business case approval prior to commencement of award of contract and procurement process is: a) Up to £500,000 Senior Leadership Team b) Over £500,000 Governing Body
Following approval of the business case, the Quotation and Tendering process below must be followed:
Quotation and Tendering
If the contract exceeds the OJEU limit for part A Supplies and Services and the company is not PASA or Office of Government Commerce (OGC) approved, formal OJEU tendering processes are required to be followed. a) Up to £5,000 (with written quotation). a) Budget Holder b) From £5,001 to £50,000 (with two written quotations). b) Strategic Director c) From £50,001 to £75,000 (with three written quotations). c) Strategic Director
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available) d) From £75,001 to OJEU limit (with formal tenders). d) Chief Officer / Chief Finance Officer e) From OJEU limit to £999,999 (Open competition by sealed tender, or OGC or equivalent Framework). e) Chief Officer / Chief Finance Officer f) From £1,000,000 (Open competition by sealed tender, or OGC or equivalent Framework). f) Governing Body
Waiving of formal tendering procedures in accordance with SFIs Chief Officer
7. Fees and Charges
Chief Finance Officer Income generation and other setting of charges.
8. Losses and Write Offs a) Up to £25,000 a) Strategic Head of Finance b) Over £25,000 b) Chief Finance Officer
9. Petty Cash a) Petty cash disbursements up to £75 per item a) Budget holder b) Petty cash disbursements over £75 per item b) Chief Finance Officer
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available) c) Petty cash replenishment request c) Strategic Head of Finance, Senior Finance Manager (Corporate)
10. Individual Funding Requests (IFR) a) Approval of IFR up to £50,000 a) IFR Panel b) Approval of IFR over £50,000 b) Chief Finance Officer or Chief Officer
11. Personnel and Pay a) Strategic Director (with prior Strategic Head a) Authority to fill funded posts of the establishment with permanent staff. of Finance confirmation of funding) b) Authority to appoint staff to post not on formal establishment b) Chief Financial Officer or Chief Officer c) Granting of additional increment to staff within budget (outside A4C) c) Chief Financial Officer or Chief Officer d) All requests of upgrading or altering to grades d) Chief Financial Officer or Chief Officer e) Additional staff to the agreed establishment within specifically allocated finance e) Chief Financial Officer or Chief Officer f) Authority to complete standing data form affecting pay, new starters, variations and leavers f) Immediate Line Manager (subject to prior approval of Establishment Control Form) g) Budget Holder g) Authority to authorise overtime h) Budget Holder h) Authority to authorise travel and subsistence
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
Leave i) Immediate Line Manager i) Approval of annual leave and study leave j) Immediate Line Manager j) Compassionate leave up to 3 days k) Strategic Director k) Compassionate leave up to 6 days l) Immediate Line Manager l) Special and Carers leave arrangements up to 3 days m) Strategic Director m) Special and Carers leave arrangements up to 6 days n) Immediate Line Manager n) Leave without pay o) Strategic Director o) Time off in lieu p) Automatic approval within national guidance p) Maternity, Paternity and Adoption leave, paid and unpaid
Sick Leave q) Chief Finance Officer q) Extension of sick leave of half of pay up to 3 months r) Chief Finance Officer r) Return to work part-time on full pay to assist recovery s) Chief Finance Officer s) Extension of sick leave on full pay t) Governing Body t) Compensation, redundancy and compromise agreements
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Matter Delegated Delegation (All financial limits in this schedule are subject to adequate budgets being available)
u) Establishment of rates of pay outside A4C u) Governing Body
Financial Provisions and Decision Making Limits for Primary Care Commissioning
1. The CCG shall ensure that any decisions in respect of the Delegated Functions and which exceed the financial limits set out below are only taken:
1.1. by the following persons and/or individuals set out in column 2 of Table 1 below; and 1.2. following the approval of NHS England (if any) as set out in column 3 of the Table 1 below.
2. NHS England may, from time to time, update Table 1 by sending a notice to the CCG of amendments to Table 1.
Decision Person/Individual NHS England Approval
General
Taking any step or action in relation to the CCG Chief Officer or Chief Finance Officer or NHS England Head of Legal Services settlement of a Claim, where the value of Chair and the settlement exceeds £100,000 Local NHS England Team Director or Director of Finance
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Decision Person/Individual NHS England Approval
Any matter in relation to the Delegated CCG Chief Officer or Chief Finance Officer or Local NHS England Team Director or Functions which is novel, contentious or Chair Director of Finance or repercussive NHS England Region Director or Director of Finance or
NHS England Chief Executive or Chief Financial Officer
Revenue Contracts
The entering into of any Primary Medical CCG Chief Officer or Chief Finance Officer or Local NHS England Team Director or Services Contract which has or is capable of Chair Director of Finance having a term which exceeds five (5) years
Capital
As at the date of this Agreement, the CCG will not have delegated or directed responsibility for decisions in relation to Capital expenditure (and these decisions are retained by NHS England) but the CCG may be required to carry out certain administrative services in relation to Capital expenditure under clause 13 (Financial Provisions and Liability).
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QUALITY COMMITTEE
DRAFT TERMS OF REFERENCE V2.1
1. Accountability arrangements and authority
The Quality Committee has been established as a committee of the Governing Body, in accordance with the CCG’s constitution, standing orders and scheme of delegation.
The remit, responsibilities, membership and reporting arrangements of the Quality Committee are set out in these terms of reference and shall have affect as if incorporated into the CCG’s constitution. The Quality Committee has no executive powers, other than those specifically delegated in these terms of reference.
The Quality Committee is accountable to the Governing Body.
The Quality Committee is authorised to investigate any activity within its terms of reference. It is authorised to seek any information it requires within its remit, from any employee of the CCG or member of the Governing Body or Senior Leadership Team and they are directed to co-operate with any request made by the Committee within its remit as outlined in these terms of reference.
The Quality Committee is authorised to obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary. In doing so the committee must follow any procedures put in place by the CCG for obtaining legal or professional advice.
2. Relationships and reporting
The Quality Committee is accountable to the Governing Body.
Draft minutes of the Quality Committee meetings will be circulated to members within 5 working days of a meeting and will be subject to ratification by the next Committee meeting.
Minutes of the Quality Committee will be provided to the Governing Body. The Chair of the Quality Committee shall draw to the attention of the Governing Body and or CCG Council or representatives any significant issues or risks relevant to the CCG.
The Quality Committee will present annual report of its work to the CCG Council via the CCG’s Annual Report. As required by CCG Annual Report guidance this will, as a minimum, include information about: key responsibilities, membership, attendance records and highlights of the Committee’s work over the year.
Reports on specific issues will also be prepared when necessary for consideration by the Governing Body, Senior Leadership Team and or CCG Council and or representatives.
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The Primary Care Commissioning Committee (PCCC) will be responsible for the comprehensive performance and quality management. The Quality Committee will in pursuit of its operating model, review priority themes and issues and provide assurance to the Governing Body. In so doing it will work closely with the chair of the PCCC and the Primary Care Contracts Assurance Group (CAG).
3. Role and function
The Quality Committee is responsible for advising and supporting the governing body in:
providing assurance on the quality of services commissioned; and
promoting a culture of continuous improvement and innovation with respect to safety of services, clinical effectiveness and patient experience
identifying issues for escalation to the System Quality Committee for a system- wide quality improvement approach
The scope of the Quality Committee will be all services commissioned by the CCG, including those delegated by NHS England, for children, young people and adults including those services that are jointly commissioned with the local authority and those services commissioned from the voluntary and community sectors.
4. Responsibilities
To provide the CCG with an assurance and scrutiny function in relation to quality of all commissioned services relating specifically to patient safety, patient experience and clinical effectiveness, and to ensure appropriate action is taken where such assurance is lacking.
Test, challenge, inquire and explore intelligence in a wide range of forms evidencing the quality, safety, effectiveness and impact on clinical health outcomes of services commissioned to identify areas of concern and good progress, commission and approve action plans and other initiatives in relation to areas of concern. Intelligence considered will include: o Data analysis and contract performance intelligence o Patients’, service users’ and carers’ reports, surveys, complaints and concerns o Evidence from key clinicians and managers from commissioned services o Other intelligence agreed to be important and reliable
To ensure that all services, where possible are reflective of and responsive to local populations and people’s experiences
On the basis of the tests, challenges, inquiries and explorations of intelligence, provide assurance to the governing body of the quality, safety, and effectiveness of commissioned services, and the contribution services make to achieving good
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health outcomes for local people. Where assurance cannot be provided in part or in full, to provide the governing bodies with details of remedial actions being taken and or being recommended.
Commission or receive (as appropriate) and review reports arising from the following, and commission and approve action plans and other remedial initiatives in line with agreed processes and procedures, for: o serious incidents (SIs) o serious case reviews (SCRs) o domestic homicide reviews (DHRs) o child and adult safeguarding investigations o ‘never events’ o system failures o individual care failures o ‘near misses’ o CQUINs ( commissioning for quality and innovation)
To ensure that any concerns regarding clinical outcomes within commissioned services is effectively identified and managed via contract mechanisms and that the wider implications and trends are addressed.
Where independent investigation reports have been commissioned either by the committee or by another authorising body, to recommend publication plans in light of the NHS’s commitment to transparency and openness
Identify, where appropriate, issues relating to data quality, completeness or accuracy of intelligence in all forms, and commission improvements where required
To discharge our responsibilities in relation to securing continuous improvement in quality of general medical services (including approval of arrangements for supporting NHS England in discharging its responsibilities for this).
Regularly review the CCG’s clinical risk management processes, systems and culture, to ensure their effectiveness, commissioning changes and improvements as appropriate. This should also include the CCGs governing body assurance framework and risk register.
Undertake such quality surveillance activity for commissioned services as from time to time required by the West Yorkshire Quality Surveillance Group.
To review changes in national guidance relating to quality and safety, together with any implications for the CCG.
Maintain appropriate liaison with regulatory bodies especially the Care Quality Commission and NHS Improvement and any relevant professional regulatory bodies in order to ensure appropriate information flows on matters within the committee’s remit.
To support at all times the creation, maintenance and development of a patient- focused culture within the CCGs and the wider health system
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Advise the Senior Leadership Teamin the formulation of overall clinical commissioning strategy including the scrutiny of QIPP plans to ensure quality is not compromised by financial imperatives.
Review and monitor the Corporate Risk Register in respect of quality risks. Request action by accountable individuals to manage aforementioned risks and variation in performance, ensuring plans are put in place to address the achievement of objectives and targets. Ensure that variance against target performance levels is reflected in the Risk Register reports and Governing Body Assurance Framework as appropriate.
To review and approve any CCG policies and procedures relevant to the committee’s remit.
5. Membership
Lay Member for Quality (incorporating the statutory Lay Member for Patient and Public Involvement role) Lay Member for Primary Care Commissioning Registered Nurse Secondary Care Consultant x 2 GP member of the Strategic Leadership Team (Strategic Clinical Director) Strategic Director of Quality and Nursing Associate Director of Quality and Nursing Associate Director of Organisational Effectiveness
Members can send deputies to represent them. Deputies will count towards quorum but will only have voting rights if they have formal acting up status.
Members are normally expected to attend at least 75% of meetings during the year.
6. Chair
The Chair of the Quality Committee shall be the Lay Member for Quality. The Chair of the Quality Committee shall not also act as the Chair of the CCG’s Audit and Governance Committee.
The Deputy Chair of the Quality Committee shall be one of the Lay or Professional Healthcare members of the committee as determined by the committee.
Where both Quality Committee Chair and Deputy Chair cannot attend or is conflicted, committee members present will elect one of their numbers to act as the Chair on that occasion.
7. Decision-taking and voting
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Generally, it is expected that meeting decisions will be reached by consensus. Should this not be possible, each voting member of the Quality Committee will have one vote. Decisions will be by majority vote.
In the event of a tied vote, the Chair of the Quality Committee will have the second and casting vote.
Should a vote be taken, the outcome of the vote and any dissenting views will be recorded in the minutes of the meeting.
8. In attendance
Regular attendees will include:
Strategic Head of Patient Quality & Safety Senior Head of Quality Improvement Head of Engagement
Other CCG staff may be requested to attend in an advisory capacity.
Any member of the Governing Body or Senior Leadership Team or a representative of Healthwatch is entitled and encouraged to attend this committee with observer status.
9. Quorum
50% of the membership to include the:
Chair or Deputy Chair; One of the other Lay or Professional Healthcare Members; Strategic Director of Quality and Nursing or Associate Director of Quality and Nursing (if deputising for the Strategic Director); and Clinical member of the Senior Leadership Team
10. Frequency of meetings
The Quality Committee will normally meet monthly with a minimum of 10 meetings per annum.
11. Sub-committees / groups
The Quality Committee is authorised to create sub-groups or working groups as are necessary to fulfil its responsibilities within these terms of reference.
The Quality Committee may not delegate executive powers delegated to it, unless expressly authorised by the Governing Body via an amendment to these terms of reference and remains accountable for the work of any such groups.
12. Conduct
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The Quality Committee will have due regard to, and operate within, the constitution, standing orders, the scheme of delegation, the prime financial policies and other policies and procedures of the CCG.
The Quality Committee will conduct its business in accordance with relevant national guidance, including codes of practice such as the Nolan Principles, which are included in the CCG constitution.
13. Management of conflicts of interest
The Quality Committee will adhere to the CCG’s Business Conduct & Conflicts of Interest Policy.
If any member of the Quality Committee has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The Chair of the meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct & Conflicts of Interest Policy.
The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned:
Take part in the discussion but not in the decision-taking Did not take part in either the discussion or decision-taking Take part in the discussion and left the meeting for the decision or Left the meeting for the whole of the item
In making this decision the Chair will need to consider the following points:
the nature and materiality of the decision the nature and materiality of the declared interest(s) the availability of relevant expertise as a general rule (and subject to the judgement of the Chair), if an interest involves a financial interest or a significant non-financial interest, the individual should be asked to leave the meeting for the whole item
14. Administration
The Quality team provide administrative support to the Quality Committee and will ensure that papers are issued at least five working days before a meeting and that draft minutes are circulated within 5 working days after the meeting. The Quality team will be responsible for supporting the Chair in the management of the Quality Committee business and for drawing the committee’s attention to best practice, national guidance and other relevant documents as appropriate.
The Quality team, in conjunction with the Chair of the Quality Committee and staff from other teams, will develop and maintain a work programme to inform and guide the work of the committee.
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15. Urgent matters arising between meetings
The Chair or Deputy Chair of the Quality Committee in consultation with the Strategic Director of Quality and Nursing, or the Accountable Officer, or one of the deputies in the quality team may also act on urgent matters arising between meetings of the Committee.
Where an urgent decision has been taken a report, along with any background documentation, will be taken to the next meeting of the Quality Committee, where the Chair or Deputy Chair will explain the reason for the action taken.
16. Monitoring of performance and compliance
The Quality Committee will review its own effectiveness, its compliance with its terms of reference and the terms of reference document itself at least annually and a report of the outcomes of this review will be produced and reported to the Governing Body (or to the Audit and Governance Committee on behalf of the Governing Body).
17. TOR review date & approving body
Annually (during Quarter 1 of the year), or as and when legislation or best practice guidance is updated.
Any amended Terms of Reference will be agreed by the Quality Committee for approval by a subsequent meeting of the Governing Body
Version Control
V. Detail Approval V1.0 BD&C CCG draft version Approved by Chairs action 01.04.20 – to go to the next Gov Body for ratification. V1.1 Amendment to specify that two Secondary Care To go for approval Gov Body May Consultants are members of the committee. 2020
V2.0 As above Approved by Gov Body 12.05.20 V2.1 Review and update. Reference to Clinical Boards replaced with SLT.
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Terms of Reference
Finance and Performance Committee V1.3
1. Accountability arrangements and authority
The Finance and Performance Committee has been established as a committee of the Governing Body, in accordance with the CCG’s constitution, standing orders and scheme of delegation. The Finance and Performance Committee is accountable to the Governing Body and will provide the Governing with assurance on its work.
The remit, responsibilities, membership and reporting arrangements of the Finance and Performance Committee are set out in these terms of reference. The Finance and Performance Committee has no executive powers, other than those specifically delegated in these terms of reference.
The Finance and Performance Committee is authorised to investigate any activity within its terms of reference. It is authorised to seek any information it requires within its remit, from any employee of the CCG or member of the Governing Body or Senior Leadership Team and they are directed to co-operate with any request made by the Committee within its remit as outlined in these terms of reference.
The Finance and Performance Committee is authorised to obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary. In doing so the committee must follow any procedures put in place by the CCG for obtaining legal or professional advice.
2. Relationships and reporting
The Finance and Performance Committee is accountable to the Governing Body.
Draft minutes of the Finance and Performance Committee meetings will be circulated to members within four working days of a meeting and will be subject to ratification by the next Committee meeting.
Minutes of the Finance and Performance Committee will be provided to the Governing Body. The Chair of the Finance and Performance Committee shall draw to the attention of the Governing Body any significant issues or risks relevant to that CCG.
The Finance and Performance Committee will present an annual report of its work to the CCG Council via the CCG’s Annual Report. As required by CCG Annual Report guidance this will, as a minimum, include information about: key responsibilities, membership, attendance records and highlights of the Committee’s work over the year.
Reports or verbal updates on specific issues will also be provided as necessary for the Governing Body, the Senior Leadership Team or CCG Council.
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Minutes of the System Finance & Performance Committee (SFPC) will be reported to the Finance & Performance Committee.
The SFPC provides collective focus on financial and performance outcomes for the Bradford District and Craven Health and Care System and includes representatives from the CCG, BTHFT, ANSHFT, BDCFT, CBMDC and primary care. No decision- making authority is delegated to the SFPC as a forum, however the members of the committee may make decisions on behalf of their own organisation in line with the authority delegated to them as individuals. The CCG representatives on the SFPC are the Chief Finance Officer, the Associate Director of Population Health & Wellbeing and the Strategic Head of Finance; Financial Planning and Transformation.
3. Role and function
The role of the Finance and Performance Committee is to advise and support the Governing Body through performance oversight of key financial and performance indicators and or targets, including QIPP, as specified in the CCG’s strategic and operational plans.
The Finance and Performance Committee is responsible for advising and supporting the Governing Body in:
I. scrutinising and tracking the key delivery of key financial and service priorities, outcomes and targets as specified in the CCG’s Strategic and Operational Plans II. ensuring that the CCG develops and adopts appropriate policies and procedures to support effective governance of financial and performance matters
Whilst the Finance and Performance Committee is principally concerned with ensuring that the CCG meets its statutory financial and operational plan targets, it discharges its responsibilities recognising the ‘Act as One’ ethos and the role of the System Finance & Performance Committee in the Bradford Place that seeks to ensure the most effective management of Place resources in relation to Place priorities.
4. Responsibilities
Finance
Ensure financial management achieves value for money, efficiency and effectiveness in the use of resources with a continuing focus on cost reduction and achievement of efficiency targets. Identify and manage mechanisms put in place by the CCG to drive cost improvements. Review the CCG’s annual budget and capital plan, reviewing key assumptions and ensuring national planning requirements are achieved.
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Monitor and review the achievement of the financial plan, including QIPP plans. Provide a forum to evaluate requirements and advise the Governing Body on committing resources to respond to performance issues and potential investments. Ensure that processes for financial management (including reporting) are robust. Monitor and oversee the delegated budget for commissioning primary medical care services, including oversight of additional funding identified outside of delegated budgets. Advise the Governing Body on the content of the Corporate Finance Report.
Performance
The Committee shall carry out a monthly review of the overall performance of the CCG. This shall include:
Review performance against the delivery of the Operational Plan. Review progress and achievement against agreed national, regional and local targets which support the delivery of the CCG’s strategy and plans, with a particular focus on “must-dos” and external regulation. Receive, and review assurance of, contract management and value for money from commissioning support services. An assessment of pressures within the whole system and how these affect contracts and performance. Opportunities to further improve performance where not discussed by other committees. Any additional national, regional or local requirements as determined by NHS England.
In addition the Committee will:
Provide advice and or feedback to management teams on the setting of performance indicators within plans and strategies. Recognise areas of good practice and ensure they are embedded along with the use of benchmarking tools e.g. better care better value indicators, and programme budgeting. Ensure the delivery of any action plans stemming from performance issues. Ensure that processes for performance management (including reporting) are robust Advise the Governing Body on the content of the Corporate Performance Report. Make recommendations to the Governing Body on developments to the CCG’s performance management framework.
Risk Management
Review and monitor the Corporate Risk Register in respect of finance, performance, contracting and corporate risks.
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Request action by accountable individuals to manage aforementioned risks and variation in performance, ensuring plans are put in place to address the achievement of objectives and targets. Ensure that variance against target performance levels is reflected in the Risk Register reports and Governing Body Assurance Framework as appropriate. Ensure that effective arrangements are in place for business continuity and emergency planning.
Other Duties
In addition to the Finance and Performance Committee tasks outlined above, the committee will:
Review and approve standing financial instructions and any policies, procedures and guidelines within the remit of the Committee. Ensure that all necessary actions are undertaken by the management team to deliver corporate objectives within expected timescales. Undertake any other responsibilities as deemed appropriate by the Governing Body. Have oversight of procurement activity via the Contracting report. Seek assurance on arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006).
5. Membership
Lay Member for Finance and Performance
Lay Member for Audit & Governance
Strategic Clinical Director of Strategy & Planning (GP)
Chief Finance Officer
Members may send deputies to represent them. Deputies will count towards quorum but will only have voting rights if they have formal acting up status.
Members are normally expected to attend at least 75% of meetings during the year.
6. Chair
The Chair of the Finance and Performance Committee shall be the Lay Member for Finance & Performance.
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Where the Finance and Performance Committee Chair cannot attend or is conflicted one of the other committee members (not conflicted) will be selected to act as the Chair.
7. Decision-taking & voting
Generally, it is expected that meeting decisions will be reached by consensus. Should this not be possible, each voting member of the Joint Finance and Performance Committee will have one vote. Decisions will be by majority vote.
In the event of a tied vote, the Chair of the Finance and Performance Committee meeting will have the second and casting vote.
Should a vote be taken, the outcome of the vote and any dissenting views will be recorded in the minutes of the meeting.
8. In attendance
Regular attendees will include:
Associate Director of Population Health & Wellbeing Strategic Head of Keeping Well Strategic Head of Finance – Financial Planning & Transformation Senior Head of Keeping Well
On a quarterly basis, attendees will include:
Associate Director of Quality and Nursing - for Personalised Commissioning update. Senior Head of Medicines Optimisation - for Prescribing update.
Other CCG staff may be requested to attend in an advisory capacity.
Any member of the Governing Body or Senior Leadership Team of the CCG is entitled and encouraged to attend this committee with observer status.
9. Quorum
The committee will be quorate when three out of four members are present (deputies count towards quorum).
10. Frequency of meetings
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The Finance and Performance Committee will normally meet monthly, with a minimum of 10 meetings per annum.
11. Sub-committees / groups
The Finance and Performance Committee is authorised to create sub-groups or working groups as are necessary to fulfil its responsibilities within these terms of reference.
The Finance and Performance Committee may not delegate executive powers delegated within these Terms of Reference, unless expressly authorised by the CCG Council or representative of the CCG and remains accountable for the work of any such groups.
12. Conduct
The Finance and Performance Committee will have due regard to, and operate within, the constitution, standing orders, the scheme of delegation, the prime financial policies and other policies and procedures of the CCG.
The Finance and Performance Committee will conduct its business in accordance with relevant national guidance, including codes of practice such as the Nolan Principles, which are included in the CCG constitution.
13. Management of conflicts of interest
The Finance and Performance Committee will adhere to the CCG’s Business Conduct & Conflicts of Interest Policy.
If any member of the Finance and Performance Committee has an actual or potential conflict of interest in any matter and is present at the meeting at which the matter is under discussion, they will declare that interest at the start of the meeting and again at the relevant agenda item and this shall be recorded in the minutes. The Chair of the meeting will determine how the interest will be managed in accordance with the CCG’s Business Conduct & Conflicts of Interest Policy (CCG websites)
The minutes must specify how the Chair decided to manage the declared interest, i.e. did the individual(s) concerned:
Take part in the discussion but not in the decision-taking Did not take part in either the discussion or decision-taking Take part in the discussion and left the meeting for the decision or Left the meeting for the whole of the item
In making this decision the Chair will need to consider the following points:
the nature and materiality of the decision
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the nature and materiality of the declared interest(s) the availability of relevant expertise as a general rule (and subject to the judgement of the Chair), if an interest involves a financial interest or a significant non-financial interest, the individual should be asked to leave the meeting for the whole item
14. Administration
The Finance team will provide administrative support to the Finance and Performance Committee and will ensure that papers are issued at least five working days before a meeting and that draft minutes are circulated within five working days after a meeting.
The Finance team will be responsible for supporting the Chair in the management of the Finance and Performance Committee’s business and for drawing the committee’s attention to best practice, national guidance and other relevant documents as appropriate.
The Finance team, in conjunction with the Chair of the Finance and Performance Committee will develop and maintain a work programme to inform and guide the work of the committee.
15. Urgent matters arising between meetings
The Chair of the Finance and Performance Committee in consultation with one out of the Chief Officer or the Chief Finance Officer may also act on urgent matters arising between meetings of the Committee.
Where an urgent decision has been taken a report, along with any background documentation, will be taken to the next meeting of the Finance and Performance Committee, where the Chair will explain the reason for the action taken.
16. Monitoring of performance and compliance
The Finance and Performance Committee will review its own effectiveness, its compliance with its terms of reference and the terms of reference document itself at least annually and a report of the outcomes of this review will be produced and reported to the or to the Audit Committee on behalf of the Governing Body.
17. TOR review date & approving body
Annually, or as and when legislation or best practice guidance is updated.
Any amended Terms of Reference will be agreed by the Finance and Performance Committee for approval by a subsequent meeting of the Governing Body.
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Version Control
V. Detail Approval V1.0 1st BD&C approved version Approved by Chair’s action 01.04.20 and subsequently ratified by Gov Body 12.05.20 V1.1 Draft amendments for consideration by F&P Jan 2021. Confirmation of members, attendees and quorum, clarification to Role & Function re F&P role re Act as One.
V1.2 Amendments following discussion at January 2021 F&P and discussion with the Clinical Chair regarding allocation of independent members to F&P and Quality committees.
V1.3 Amendments following discussion at 4 February F&P
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SCHEME OF RESERVATION & DELEGATION
1. SCHEDULE OF MATTERS RESERVED TO THE CLINICAL COMMISSIONING GROUP AND SCHEME OF DELEGATION
1.1. The arrangements made by the group as set out in this scheme of reservation and delegation of decisions shall have effect as if incorporated in the group’s constitution.
1.2. The clinical commissioning group remains accountable for all of its functions, including those that it has delegated.
For the Financial Scheme of Delegation – please see the Constitution Appendix 4
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
REGULATION AND Determination of the arrangements by which the members of the group CONTROL approve those decisions that are reserved for the membership. REGULATION AND Consideration and approval of applications to the NHS England on any CONTROL matter concerning changes to the group’s constitution.
REGULATION AND Approve amendments to the CCG’s constitution, ahead of submission to CONTROL NHS England for review and agreement, where:
Changes are deemed to have a material impact; or Changes are proposed to the reserved powers of the members or the role and appointment of GP members of the senior leadership team; or At least half (50%) of all the Governing Body Members formally request that the amendments be put before the membership for approval
348 349
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
REGULATION AND Approve minor amendments proposed by the Accountable Officer to (i) CONTROL the CCG’s constitution, ahead for submission to NHS England for review and agreement or to (ii) the CCG’s scheme of delegation, where;
Changes are required for legal reasons Changes are not thought to have a material impact; or Changes are not proposed to the reserved powers of the members or the role and appointment of member practice representatives (including the GP members of the senior leadership team). REGULATION AND Grant authority to act on its behalf to: CONTROL (i) any member of the Governing Body or Senior Leadership Team; (ii) a committee or sub-committee of the Governing Body, or of the CCG; (iii) a member of the CCG who is an individual (but not a member of the Governing Body); and (iv) any other individual who may be from outside the organisation and who can provide assistance to the CCG in delivering its functions.
349 350
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
REGULATION AND Grant authority to act on its behalf to: CONTROL (i) any member of the Senior Leadership Team; (ii) a committee or sub-committee of the Governing Body or of the CCG; (iii) a member of the CCG who is an individual (but not a member of Senior Leadership Team); and (iv) any other individual who may be from outside the organisation and who can provide assistance to the CCG in delivering its functions.
REGULATION AND Approval of terms of reference of the senior leadership team and any CONTROL other committees of the CCG.
REGULATION AND Approval of terms of reference of committees of the governing body. CONTROL
REGULATION AND Exercise or delegation of those functions of the clinical commissioning CONTROL group which have not been retained as reserved by the group, delegated
to the governing body, committee or sub-committee or specified member or employee REGULATION AND Approve the group’s standing financial instructions (other the financial Finance & CONTROL scheme of delegation which forms part of the constitution) and detailed Performance financial policies. Committee REGULATION AND Approve arrangements for managing individual funding requests. CONTROL APPOINTMENTS & Determine the arrangements for identifying practice members to represent REMOVALS practices in matters concerning the work of the CCG.
350 351
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
APPOINTMENTS & Electing the chair of the CCG council REMOVALS APPOINTMENTS & Determine the process to assess the eligibility (including competency) of REMOVALS candidates for GP senior leadership team roles, including the Clinical Chair subject to approval by the CCG Council) APPOINTMENTS & Approve the process for assessing the eligibility (including competency) of REMOVALS candidates for GP senior leadership team roles. APPOINTMENTS & Electing candidates to GP senior leadership team roles (where there is REMOVALS more than one eligible candidate), on the basis of one GP (partner and salaried), one vote arrangement.
APPOINTMENTS & Approve the process for appointing the clinical chair. REMOVALS APPOINTMENTS & Selection of: Clinical REMOVALS (i) deputy chair of the CCG and of the governing body (lay Chair member) (ii) senior independent director (lay member) – in liaison with the Chair of the CCG Council
(iii) deputy clinical chair (GP member of the senior leadership team) (iv) the second GP senior leadership team member of the governing body (if not the same individual as (iii) above)
APPOINTMENTS & Approve the process for the selection and appointment of the non-elected REMOVALS members of the governing body.
351 352
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
APPOINTMENTS & Determine and approve the process for selecting and appointing REMOVALS managerial members of the senior leadership team and the chief clinical information officer. APPOINTMENTS & Removal of GP senior leadership team members and non-employee REMOVALS members of the governing body, via a 75% majority vote of confidence at a meeting of the council of members. APPOINTMENTS & Referral of employee members of the governing body or senior leadership REMOVALS team for management under the CCG’s HR policies and procedures, via a 75% majority vote of confidence at a meeting of the council of members. APPOINTMENTS & Following initial appointment, re-appoint individuals to GP senior Clinical REMOVALS leadership team role and the lay members, registered nurse and Chair secondary care consultant roles, subject to satisfactory performance appraisal and the individuals continuing to meet the appointment criteria.
Time periods for re-appointments are limited to: GP senior leadership team members – up to a maximum of 6 years, unless otherwise agreed with the CCG Council lay members, registered nurse and secondary care consultant – up to a maximum of 9 years
STRATEGY AND Agree the vision, values and overall strategic direction of the group PLANNING (following development of the same by the Senior Leadership Team)
STRATEGY AND Approval of the group’s operating structure: (i) (ii) Clinical PLANNING (i) staffing and managerial Chair
(ii) clinical leadership
STRATEGY AND Approval of the CCG’s commissioning plans and strategies. PLANNING
352 353
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
STRATEGY AND Approval of the CCG’s corporate budgets (the financial plan that PLANNING underpins the commissioning plan) that meet the CCG’s financial duties. STRATEGY AND Approval of consultation arrangements for the group’s financial and
PLANNING commissioning plans. STRATEGY AND Approval of variations to the approved budget where variation would have PLANNING a significant impact on the overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims. STRATEGY AND Make decisions on the review, planning and procurement of services PLANNING (except those where authority has been delegated to another group) STRATEGY AND Make decisions on the review, planning and procurement of primary Primary PLANNING medical care services (as per the terms of the delegation agreement with Care NHS England). [Note: PCCC decisions are binding on both NHS England Commissio and the CCG i.e. they cannot be over-turned by either party] ning Committee STRATEGY AND Make decisions on the review, planning and procurement of services as Joint PLANNING specified in the work plan for the Joint Committee of West Yorkshire & Committee Harrogate CCGs. of West Yorkshire & Harrogate CCGs ANNUAL REPORTS Receive the group’s annual report and annual accounts. AND ACCOUNTS ANNUAL REPORTS Approve the group’s annual report and annual accounts. AND ACCOUNTS ANNUAL REPORTS Approve the appointment of the group’s external auditor, as advised by AND ACCOUNTS the audit & governance committee acting as the group’s ‘auditor panel’.
353 354
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
ANNUAL REPORTS Approval of the arrangements for discharging the group’s statutory AND ACCOUNTS financial duties. HUMAN Make recommendations to the governing body on the terms and RESOURCES conditions of employment / service, including remuneration, fees and allowances, pensions, gratuities and severance or redundancy payments,
for all employees, senior leadership team and governing body members (excluding the lay members) and any other persons providing services to the group, including pensions and gratuities. HUMAN Approve the terms and conditions of employment / service, including RESOURCES remuneration, fees and allowances, pensions, gratuities and redundancy payments, for all employees, senior leadership team and governing body members (excluding the lay members) and any other persons providing services to the group, including pensions and gratuities. HUMAN Approve (following consultation with the BDCFT staff partnership forum) RESOURCES human resources policies for employees and for other persons working on behalf of the group (with the exception of the disciplinary policy and the removal and relocation expenses policy where authority to approve sits with the Remuneration Committee) HUMAN Approve (following consultation with the BDCFT staff partnership forum)
RESOURCES the disciplinary policy and the removal and relocation expenses policy) HEALTH & SAFETY Approve arrangements for ensuring the CCG discharges its legal responsibilities health, safety and security. QUALITY AND Approve arrangements, including supporting policies, to minimise clinical Quality & SAFETY risk, maximise patient safety and to secure continuous improvement in Safety quality and patient outcomes. Committee QUALITY AND Approve arrangements for supporting NHS England in discharging its Quality & SAFETY responsibilities in relation to securing continuous improvement in the Safety quality of general medical services. Committee
354 355
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
OPERATIONAL AND Approve the group’s risk management framework. RISK MANAGEMENT OPERATIONAL AND Approval of the group’s business continuity plan. RISK MANAGEMENT OPERATIONAL AND Approve the internal audit, external audit and counter-fraud plans and any RISK changes to the provision or delivery of related services (other than the MANAGEMENT appointment or removal of the external auditor where authority is reserved to the governing body). OPERATIONAL AND Approve arrangements for risk sharing and / or risk pooling with other Finance & RISK organisations (for example arrangements for pooled funds with other Performance
MANAGEMENT clinical commissioning groups or pooled budget arrangements under Committee section 75 of the NHS Act 2006). OPERATIONAL AND Approve proposals for action on litigation against or on behalf of the RISK clinical commissioning group. MANAGEMENT OPERATIONAL AND Approve the group’s arrangements for business continuity and emergency RISK planning. MANAGEMENT OPERATIONAL AND Definition and taking of ‘urgent decisions’ on behalf of the governing body Clinical Chair RISK (see Standing Orders). OR OR OR MANAGEMENT OPERATIONAL AND Use of the CCG seal or execution of a document by signature (see Clinical RISK Standing Orders). OR OR Chair OR MANAGEMENT
355 356
(Chief (Chief
Policy Area Decision Body Team Senior Senior Officer Officer) Audit & Audit & embership Other (as (as Other specified) Governing Governing Committee Committee Leadership Leadership Governance Governance M Accountable Accountable CCG Council CCG Officer Chief Finance Finance Chief Remuneration Remuneration
OPERATIONAL AND Assessment of and decision-taking relating to individual funding requests IFR Panel RISK OR (as specified in MANAGEMENT IFR procedures) the Clinical Lead for IFR COMPLAINTS Approve the group’s arrangements for handling complaints. Quality
Committee
INFORMATION Approve arrangements for ensuring appropriate safekeeping and
GOVERNANCE confidentiality of data and for the storage, management and transfer of information and data. INFORMATION Approve arrangements for ensuring compliance with the Freedom of
GOVERNANCE Information Act 2000. TENDERING AND Approve tenders and contracts. As per CONTRACTING thresholds set out in the Financial Scheme of Delegation. PARTNERSHIP Approve frameworks for partnership working that lie outside of the WORKING definition of ‘joint commissioning of services’ (e.g West Yorkshire & Harrogate Health & Care Partnership MOU or the Bradford District & Craven Strategic Partnering Agreement). PARTNERSHIP Approve arrangements for joint commissioning of services with other
WORKING CCGs, NHS England and or with the local authority. PARTNERSHIP Authority to enter in to strategic or other transformation discussions with
WORKING partner organisations.
356 Appendix357 4: Financial Scheme of Delegation
Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
1. Bank Accounts
Maintenance and operation in accordance with mandate approved by the Governing Chief Finance Officer Body Senior Finance Manager (Corporate) Day to day operation of organisation’s Bank Accounts Strategic Head of Finance Authorisation for Cash Limit Drawdown
2. Budget Management
Responsibility for maintaining expenditure within budgets: Limits are set per transaction
a) For designated budgets (pay and non pay) a) Budget holder
b) Reserves b) Chief Finance Officer
c) At Clinical Commissioning Group level. c) Chief Finance Officer or Chief Officer
Transaction limits are: Up to £5,000 Budget Holder Up to £30,000 Senior Head of Strategy, Change and Delivery Up to £50,000 Associate Director Up to £250,000 Strategic Director Over £250,000 Chief Finance Officer / Chief Officer
357 358 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
Approval of the CCG financial plan. Governing Body
Approval of variations to the approved budget where variation would have a significant Governing Body impact on the overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims.
3. Budget Virement
Budget virement is the process of transferring financial resources either within a single budget, or between different budgets. Budget virement limits are: a) Up to the lower of the available budget and £50,000. a) Budget Holder b) Over £50,000. b) Chief Finance Officer / Chief Officer
To effect a budget virement over £50,000, a budget virement form must be completed and authorised by the CFO. Virements between non pay and pay are subject to the establishment control process.
358 359 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
4. Existing Contracts / Agreements - Purchase of Healthcare from NHS and Non- NHS Bodies (including Foundation Trusts, Private Providers, Charities and Independent Contractors).
Signing of Annual Contracts / Service Level Agreements: a) Up to £50,000 a) Associate Director b) Up to £250,000 b) Strategic Director c) Over £250,000 c) Chief Officer or Chief Finance Officer
In-year contract variations with no financial implications Associate Director
Approval of Invoices for Agreed Contracts (subject to exceptions noted below): a) Up to £5,000 a) Budget Holder b) Up to £30,000 b) Senior Head of Strategy, Change and Delivery c) Up to £50,000 c) Associate Director d) Up to £250,000 d) Strategic Director e) Over £250,000 e) Chief Finance Officer or Chief Officer
359 360 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
Exception 1
Commissioning and Healthcare Contract Invoices: Invoices under SLA, Contracts with Foundation Trusts or partnership agreements with Local Authorities or Collaborative Arrangements with other CCGs where the SLA/Contract has been formally agreed: a) Up to £25,000,000 a) Associate Director / Strategic Head of Finance b) Over £25,000,000 b) Chief Finance Officer or Chief Officer
Exception 2
Continuing Healthcare, Personal Health Budget and Funded Nursing Care Invoices where care package has been agreed: a) Up to £50,000 a) Head of PCD b) Up to £500,000 b) Associate Director of Nursing and Quality c) Up to £5,000,000 c) Strategic Director of Quality and Nursing d) Over £5,000,000 d) Chief Finance Officer or Chief Officer
360 361 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
Exception 3
Primary Care payment schedules in accordance with GP Contract requirements : a) Senior Head of Strategy Change a) Up to £100,000 and Delivery (Primary Care)
b) Associate Director of Keeping Well b) Up to £1,000,000 (Primary Care)
c) Over £1,000,000 c) Chief Finance Officer
Authorisation of Non-Invoice payments and urgent payments on Oracle following Strategic Head of Finance, Senior approval as above. Finance Manager (Corporate)
5. Non-Contracted Healthcare Activity Invoices
Invoice approval limits are:
a) Up to £10,000 a) Head of Strategy, Change and Delivery
b) Up to £30,000 b) Senior Head of Strategy, Change and Delivery
c) Over £30,000 c) Associate Director
361 362 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
6. New Expenditure (whole life costs).
Continuing Healthcare, Personal Health Budget and Funded Nursing Care Packages of Care
Care package approval limits are: a) Up to £5,000.00 per week a) Senior Clinical Commissioning Manager b) Up to £10,000.00 per week b) Senior Head of Personalised Commissioning
c) Associate Director of Nursing and c) Over £10,000.00 per week Quality
Business Cases
The threshold for all new contracts (NHS and Non-NHS) which require business case approval prior to commencement of award of contract and procurement process is:
Senior Leadership Team a) Up to £500,000
Governing Body b) Over £500,000
Following approval of the business case, the Quotation and Tendering process below
362 363 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available) must be followed:
Quotation and Tendering
If the contract exceeds the OJEU limit for part A Supplies and Services and the company is not PASA or Office of Government Commerce (OGC) approved, formal OJEU tendering processes are required to be followed. a) Up to £5,000 (with written quotation). a) Budget Holder b) From £5,001 to £50,000 (with two written quotations). b) Strategic Director c) From £50,001 to £75,000 (with three written quotations). c) Strategic Director d) From £75,001 to OJEU limit (with formal tenders). d) Chief Officer / Chief Finance Officer e) From OJEU limit to £999,999 (Open competition by sealed tender, or OGC or e) Chief Officer / Chief Finance Officer equivalent Framework). f) From £1,000,000 (Open competition by sealed tender, or OGC or equivalent f) Governing Body Framework).
Waiving of formal tendering procedures in accordance with SFIs Chief Officer
7. Fees and Charges
Income generation and other setting of charges. Chief Finance Officer
363 364 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
8. Losses and Write Offs a) Up to £25,000 a) Strategic Head of Finance b) Over £25,000 b) Chief Finance Officer
9. Petty Cash a) Petty cash disbursements up to £75 per item a) Budget holder b) Petty cash disbursements over £75 per item b) Chief Finance Officer c) Petty cash replenishment request c) Strategic Head of Finance, Senior Finance Manager (Corporate)
10. Individual Funding Requests (IFR) a) Approval of IFR up to £50,000 a) IFR Panel b) Approval of IFR over £50,000 b) Chief Finance Officer or Chief Officer
11. Personnel and Pay a) Authority to fill funded posts of the establishment with permanent staff. a) Strategic Director (with prior Strategic Head of Finance confirmation of funding)
364 365 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available)
b) Authority to appoint staff to post not on formal establishment b) Chief Financel Officer or Chief Officer c) Granting of additional increment to staff within budget (outside A4C) c) Chief Finance Officer or Chief Officer d) All requests of upgrading or altering to grades d) Chief Finance Officer or Chief Officer e) Additional staff to the agreed establishment within specifically allocated finance e) Chief Finance Officer or Chief Officer f) Authority to complete standing data form affecting pay, new starters, variations and f) Immediate Line Manager leavers (subject to prior approval of Establishment Control Form) g) Authority to authorise overtime g) Budget Holder h) Authority to authorise travel and subsistence h) Budget Holder
Leave i) Approval of annual leave and study leave i) Immediate Line Manager j) Compassionate leave up to 3 days j) Immediate Line Manager k) Compassionate leave up to 6 days k) Strategic Director l) Special and Carers leave arrangements up to 3 days l) Immediate Line Manager m) Special and Carers leave arrangements up to 6 days m) Strategic Director n) Leave without pay n) Immediate Line Manager
365 366 Delegation Matter Delegated (All financial limits in this schedule are subject to adequate budgets being available) o) Time off in lieu o) Strategic Director p) Maternity, Paternity and Adoption leave, paid and unpaid p) Automatic approval within national guidance Sick Leave q) Extension of sick leave of half of pay up to 3 months q) Chief Finance Officer r) Return to work part-time on full pay to assist recovery r) Chief Finance Officer s) Extension of sick leave on full pay s) Chief Finance Officer t) Compensation, redundancy and compromise agreements t) Governing Body u) Establishment of rates of pay outside A4C u) Governing Body
Financial Provisions and Decision Making Limits for Primary Care Commissioning
1. The CCG shall ensure that any decisions in respect of the Delegated Functions and which exceed the financial limits set out below are only taken:
1.1. by the following persons and/or individuals set out in column 2 of Table 1 below; and
1.2. following the approval of NHS England (if any) as set out in column 3 of the Table 1 below.
2. NHS England may, from time to time, update Table 1 by sending a notice to the CCG of amendments to Table 1.
366 367 Decision Person/Individual NHS England Approval
General
Taking any step or action in relation CCG Chief Officer or Chief Finance Officer NHS England Head of Legal Services to the settlement of a Claim, where or Chair and the value of the settlement exceeds £100,000 Local NHS England Team Director or Director of Finance
Any matter in relation to the CCG Chief Officer or Chief Finance Officer Local NHS England Team Director or Delegated Functions which is novel, or Chair Director of Finance or contentious or repercussive NHS England Region Director or Director of Finance or NHS England Chief Executive or Chief Financial Officer
Revenue Contracts
The entering into of any Primary CCG Chief Officer or Chief Finance Officer Local NHS England Team Director or Medical Services Contract which or Chair Director of Finance has or is capable of having a term which exceeds five (5) years
Capital
As at the date of this Agreement, the CCG will not have delegated or directed responsibility for decisions in relation to Capital expenditure (and these decisions are retained by NHS England) but the CCG may be required to carry out certain administrative services in relation to Capital expenditure under clause 13 (Financial Provisions and Liability).
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DRAFT Minutes of the Audit & Governance Committee 10:00 to 12:00 24 May 2021, held virtually via Zoom
Present Bryan Millar – Lay Member for Audit & Governance (Chair) Ruby Bhatti – Lay Member for Primary Care Commissioning Neil Fell – Lay Member for Finance & Performance David Richardson – Lay Member for Quality
In Attendance Robert Maden – Chief Finance Officer Diane Lawlor – Strategic Head of Finance, Corporate Reporting and Financial Control Sue Baxter – Strategic Head of Assurance Sharron Blackburn – Deputy Head of Internal Audit, Audit Yorkshire Rashpal Khangura – Director – Public Sector Audit, KPMG Helen Kemp-Taylor, Managing Director and Head of Internal Audit, Audit Yorkshire (items Sue Jones, Head of Communications Catherine Smith – Corporate Governance Manager – (Minutes)
Apologies Liz Allen – Strategic Director of Organisation Effectiveness
1. Welcome and Apologies for Absence
Bryan Millar welcomed everyone to the meeting of the Audit & Governance (A&G) Committee. Apologies for the meeting had been received from Liz Allen.
2. Declarations of Interest
There were no declarations of interest. The CCG’s registers of interests record all interests declared and are available at: https://www.bradfordcravenccg.nhs.uk/ccg-information/publication-scheme/lists-and- registers/
3. Internal Audit Progress Report
Sharron Blackburn presented a report detailing the remaining audits to the committee before the submission of the final Head of Audit Opinion and the Annual Governance Statement for the meeting on 8th June. Sharron explained that six final audit reports have been agreed with management since the last committee meeting on 1st March 2021. The report provided an update on the audits that were agreed as ‘Must Dos’ in November 2020 and it was noted that all of the required audit work has been completed. The audits are final apart from Data
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Security and Protection Toolkit which should be finalised imminently. It was noted that reports are being drafted for children’s continuing care, reducing inequalities, programme management and Covid-19 costs.
Ruby Bhatti joined the meeting at 10:10
David Richardson raised personal health budgets as some concerning issues had been noted. Sharron explained that an action plan has been agreed for the issues identified and the key actions relate to previous recommendations on financial governance for personal health budgets in the form of audit checks and work to progress this has been agreed. Robert added that with regards to personal health budgets and recovery there has been an exercise to target more significant balances and recover the money. He explained that over the previous year there has been a capacity issue with the auditing of personal health budgets but it has been agreed that recruitment can progress for a permanent post which will form part of the action plan and will mean more robust regulation and follow-up. Diane added that a programme of audits is being created that will need to be progressed on a regular basis when the person is in post. Members were assured that a further update on the personal health budgets audit will be provided at the meeting in July.
Neil raised the first recommendation related to DBS checks and queried if this is a risk in terms of safeguarding. Sharron noted that the action is for completion by the end of June as the continuing healthcare team reported that work is needed to arrange virtual DBS checks which as checks were suspended during the pandemic. The completion date of the end of the June was queried and Sharron agreed to contact the team for an update and to feedback concerns from the committee on safeguarding – Robert asked that Gill Paxton be included in the email.
Action – Sharron to contact Nadine Cullimore and Gill Paxton for an update on the virtual DBS checks and to relay concerns from the committee on safeguarding, copying in Gill Paxton.
RESOLVED: The Audit & Governance Committee considered the assurance provided in terms of the internal audit progress report
4. Draft Head of Internal Audit Opinion 2020-21
Helen Kemp-Taylor presented the draft Head of Internal Audit Opinion for 2020/21. It was noted that the final Head of Opinion will be presented as part of the Annual Report at the meeting on 8th June and there are five audits in progress which could impact on and will be included in the final version of the paper. Helen summarised the purpose of the report highlighting the context of Covid-19 and the subsequent challenges faced by the CCG. It was noted that the Internal Audit Plan had a focus on completion of high priority audits to support the Head of Internal Audit Opinion and the position has been reported within the progress reports through the year. The internal audit risk assessment and plan for 2020/21 was reviewed on a regular basis. All of the internal audit work has confirmed with the Public Sector Internal Audit Standards during the pandemic. It was noted that an overall draft opinion of Significant Assurance has been provided, and that there is a good system of internal control designed to meet the organisation’s objectives and that controls are
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generally being applied consistently. It was noted that this testament to the work within the CCG.
Helen summarised the highlights from the report. Helen referred to the Assurance Framework and noted that the risk management framework was approved in November 2020 and an audit of the risk management and assurance framework undertaken in 2020/21 provided an opinion of Significant Assurance. There were 9 significant assurance opinions and 2 limited assurance opinions related to continuing healthcare and Personal Health Budgets noting that the opinion for Continuing Healthcare increased to significant following work undertaken to implement the recommendations which will be tested in 2021/22. The paper refers to audit work which is still underway and will be completed ahead of the final version. There have been 197 recommendations during the year of which 130 have been implemented and 2 are overdue. Helen referred to a recommendation on Mental Health Act Section 117 following a Limited Assurance opinion report in 2018/19 and highlighted that a review of the implementation of the related revised policy is included in the programme for 2021/22.
RESOLVED: The Audit and Governance Committee considered the assurance provided by the draft Head of Internal Audit Opinion for 2020/21.
5. Review of draft accounts 2020-21
Diane Lawlor presented a report which provided the Audit and Governance Committee with an explanation of the structure of the Accounts, confirmed compliance with Department of Health Accounting requirements, and provided an analysis of some of the main components of the Accounts including an explanation of significant movement between years. It was noted that as it has been the first year of the CCG since it was established in April 2020 there are no prior year comparators for income and expenditure values so Absorption Accounting has been applied and amounts from the previous CCGs values have been used to form the basis of comparisons.
Diane explained that in 2020/21 the CCG operated in line with a temporary finance regime established by NHSE/I and national guidance affecting resource allocation and expenditure alongside additional Covid-19 related costs.
Diane referred to net expenditure highlighting the Other Operating Revenue which decreased in 2020/21 compared to the previous year due to a significant decrease in funding for national schemes managed by NHS Wakefield CCG on behalf of the WY&H ICS. Diane highlighted that staff costs have increased slightly. The net impact of starters and leavers includes the TUPE transfer of BI and data quality staff from eMBED and medicines management staff from NHS Harrogate and Rural District CCG which has been offset by a reduction in clinical board members when the three CCGs merged. Other factors on staff costs include Agenda for Change increments, pension increases and additional costs due to Covid-19 such as additional hours worked.
Diane explained that there has been a significant increase in expenditure from the previous year – the report details the most significant items of expenditure and noted that the total expenditure on Covid-19 related items is £17.7m. Diane highlighted that expenditure on
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services from Foundation Trusts has increased by £9m and noted that it is difficult to show the movement through the year due to the changes in the financial regime with regards to block contract values. Diane noted a reduction in non-contract activity due to lead commissioner arrangements but that the reduction was offset by an increase in mental health investment as well as additional RIC investment and other developments related to additional resource allocations. It was highlighted that expenditure also increased due to mandated block contracts and non-contract activity and that expenditure for non-NHS bodies decreased due to the financial regime and reduced levels of locality commissioned independent sector activity and reduced other non-NHS provider non-contracted activity. However decreases were offset by Covid-19 costs, such as the hospital discharge programme, and increased funding towards the Better Care Fund, hospices, mental health and RIC. Costs have decreased by £3m from the previous year. Diane noted prescribing costs increased by 4% (£4.3m) on the previous year. Diane referred to the increase in primary care costs due to Covid-19, new national GP contract commitments and increases in Primary Care Network funding such as the extension of the Additional Roles Reimbursement Scheme.
Diane highlighted other expenditure movements of note such as the decrease of £942k due to no charges for commissioning support services, such as THIS, as costs were included in the NHS Trust block contract values however the decrease is offset by potential costs of backdated Kier VAT. There has also been a decrease in established costs which were offset by Covid-19 costs. There has been an increase in transport costs due to Covid-19. Diane added that the overall receivables balance has reduced by £3.5m from the previous year as there have not been any internal CCG recharges. Payables have increased due to continuing healthcare and additional Covid-19 costs as well as payments to private providers and the expanded Primary Care Network schemes. Diane added that there are estimated costs for continuing healthcare appeals and the cost of the TUPE transfer from eMBED as well as a provision of £1.9m relating to the ongoing review by HMRC of the VAT recovery services however HMRC have confirmed that the VAT is recoverable and the value of the provision in Accounts will not be adjusted. Other areas included the Better Care Fund pooled budget arrangements for both Bradford and North Yorkshire.
Diane summarised that the CCG met the statutory financial duties as it remained in the resource allocation and running costs have not exceeded running cost totals. It was noted that an entry was missed from the ledger but this has been adjusted in the Accounts and will be corrected in the ledger when it reopens in June - Internal Audit are aware.
Bryan thanked Diane and the finance team for the draft annual accounts report and their hard work.
Bryan recognised differences due to Covid-19 such as the block contracts with secondary care and noted that there have been adjustments to recognise less delivery. Bryan raised concern on payments for overtime and additional funding for primary care and whether there was a system to check the claims and ascertain value for money. Robert explained that there have been significant costs for primary care during Covid-19, such as reimbursement for additional staff and non-pay costs, and there was a process to collect and review claims and a significant number of claims were rejected. Robert provided assurance that there was a good process in place for claims in order to test compliance with guidance. In terms of
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CCG staff time there was a process to pay overtime when staff were asked to provide cover at the red hub or the testing site and there was a process to determine the appropriate rate to pay people and reflect the work required. The committee felt assured that there were appropriate processes in place to manage the claims.
Neil queried if the CCG had to provide payment for annual leave in staff expenses for untaken leave; Robert explained that this has not been done but if it had been done then it would have been a small liability.
RESOLVED: The Audit & Governance Committee reviewed the draft Accounts for the CCG noting the analysis in the report and approved the draft Accounts for the CCG on behalf of the Governing Body, subject to any issues arising that require amendment and the finalisation of the external audit process.
6. Review of draft annual reports (including annual governance statement)
Sue Jones presented the draft annual report which included the annual governance statement. Sue noted that due to the ongoing pandemic CCGs have been allowed to produce a slimmed down Annual Report again this year and this included omitting the performance analysis and a quality report from this year’s report as well as information on staff sickness however the latter has been included. There are some currently incomplete sections including the foreword by James Thomas as the clinical chair which will provide some context to the report and the performance section by Helen Hirst as accountable officer. Sue highlighted that there are three chapters – performance report, accountability report and the annual accounts, and noted the inclusion of trade union facility time in the second chapter.
Bryan noted that formal presentation and assurance in regards to the Annual Governance Statement could be presented to Audit & Governance Committee at the June meeting for member approval.
David suggested the inclusion of the independent sector, such as Yorkshire Clinic, in the section on ‘our main providers of service’. David also referred to patient groups and noted that some PCNs have continued to work with patient groups during the pandemic – Sue explained that this will be referenced in the foreword by James Thomas.
Neil raised the reference to A&E navigators in the section on access to care programme as one of the Act as One system transformation programmes projects and suggested that more information could be included on their work. Neil referred to the composition of the fabric of the building at Airedale Hospital as a risk and queried if the CCG should report this as a risk – Sue explained that Helen Hirst had requested that it is included under emergency planning but the inclusion has also been raised AFT.
Neil raised the constitutional targets noting that some are red due to the pandemic and queried if benchmarking measures could be included for comparison against West Yorkshire or nationally and a national average will be added to provide context of the impact of Covid- 19 on NHS constitution standards.
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7. Mental Health Investment Standard Report
Rashpal Khangura, Director, Public Sector Audit at KPMG, presented a report which provided the draft independent assurance reports for the three predecessor CCGs for 2019/20 which will be issued subject to the completion of remaining testing. The report highlights a qualification that for expenditure classified in the Mental Health Prescribing category the CCGs has used a different methodology than in the guidance, as detailed in the report. However, the report concludes that other than this issue the Mental Health Investment Standard compliance statements for 2019/20 for NHS Airedale, Wharfedale and Craven CCG, NHS Bradford City CCG and NHS Bradford Districts CCG have been properly prepared in accordance with the criteria set out in the ‘Assurance Engagement of the Mental Health Investment Standard 2019/20 - Briefing for Clinical Commissioning Groups’ and supporting guidance published by NHS England.
RESOLVED: The Audit & Governance Committee noted progress.
8. Technical Update Report
Rashpal Khangura presented the health sector update which highlighted the main technical issues which are currently having an impact on the health sector. Rashpal summarised that there are no items identified which require action. The CCG are aware of all the technical updates which are being evidenced in the financial statements. Rashpal highlighted the update related to early reflections from University Hospitals of Leicester NHS Trust noting that the review highlighted areas of concern identified with the operations of the financial reporting and governance processes at the Trust. Rashpal highlighted the need to be aware of judgments driven by financial incentives and concluded that the review highlights the role of Audit and Governance Committees in guarding against the advance and impact of the failure of financial governance and control.
RESOLVED: The Audit & Governance Committee noted the report for information.
9. External Audit Progress Report
Rashpal explained that the work to provide an audit of the accounts is progressing and there are currently no concerns raised. Prescribing figures have been highlighted. The final report will be presented to the meeting on 8th June.
RESOLVED: The Audit & Governance Committee noted the report for information.
10. VFM Risk Assessment
Rashpal presented a Value for Money risk assessment noting the need to provide a value for money conclusion, including undertaking an enhanced risk assessment and publishing a commentary on the CCG’s arrangements as stated in the updated Audit Code of Practice. The report highlights one risk regarding financial sustainability of the CCG due to the changes to the planning regime for 2021/22 and the uncertainty regarding the financial regime for the second half of 2021/22. The report highlights the plans undertaken to respond
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to the risk. Further information on work undertaken to provide assurance on the risk will be provided in the final report which will be presented to the committee on 8th June. Rashpal added that the risk is being seen in other CCGs and it might change when the second half of the year (H2) planning guidance is published.
RESOLVED: The Audit & Governance Committee noted the report for information.
11. External Audit Feedback on financial statements and draft annual report
Rashpal explained that this item was covered in item 9.
12. Committee effectiveness review
Sue Baxter presented a paper which described the annual review of committee effectiveness that was undertaken for all relevant committees and included a review of each committee’s terms of reference. Sue noted that due to the pandemic it had been agreed with Bryan as chair of the Audit and Governance Committee that a ‘light touch’ approach could be taken for the 2020/21 review and as such the review focused on general discussions with the provision of questions that could be used as prompts for discussions or the committees could use the time to reflect on their thoughts on their effectiveness. The inclusion of the Individual Funding Request Panel with the 2020/21 committee effectiveness review was noted.
Bryan added that there is a need to ensure that the committees are working effectively and working through the Assurance Framework and said that he felt assured following the discussions at each committee which identified issues and suggestions to progress. Bryan added that having the ‘light touch’ approach did not lose any content from the review and committees still had the opportunity to have an open discussion on their effectiveness, suggesting that for 2021/22 a similar light touch approach could be undertaken.
RESOLVED: The Audit & Governance Committee noted the findings of the Committee Effectiveness review and the assurance provided.
13. Date and time of next meeting
The date of the next meeting was confirmed: 8th June 10:00-12:30 via Zoom – details to follow.
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joes
Minutes of the Audit and Governance Committee 10:00 to 11:30am 8th June 2021, held virtually via Zoom
Present Bryan Millar – Lay Member for Audit & Governance (Chair) Ruby Bhatti – Lay Member for Primary Care Commissioning Neil Fell – Lay Member for Finance & Performance David Richardson – Lay Member for Quality
In Attendance Robert Maden – Chief Finance Officer Diane Lawlor – Strategic Head of Finance, Corporate Reporting and Financial Control Sue Baxter – Strategic Head of Assurance Sharron Blackburn – Deputy Head of Internal Audit, Audit Yorkshire Rashpal Khangura – Director – Public Sector Audit, KPMG Sue Jones, Head of Communications Helen Hirst, Chief Officer Liz Allen – Strategic Director of Organisation Effectiveness Bev Denton – Corporate Governance Manager – (Minutes)
Apologies
1. Welcome and Apologies for Absence
Bryan Millar welcomed everyone to the meeting of the Audit & Governance (A&G) Committee. No apologies were received.
2. Declarations of Interest
There were no declarations of interest. The CCG’s registers of interests record all interests declared and are available at: https://www.bradfordcravenccg.nhs.uk/ccg-information/publication-scheme/lists-and- registers/
3. Minutes of the meeting held on 24th May 2021
Bryan commented on an item from the minutes, Sharron Blackburn took an action from the meeting on 24th May to contact Nadine Cullimore and Gill Paxton for an update on the virtual DBS checks and to relay concerns from the committee on safeguarding. Sharron confirmed that two further staff within the team had been identified to carry out the DBS checks and training will be completed by the end of May 2021. In order to move this forward, training will
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be delivered using an example case instead. This will be included in a future audit to provide assurance.
RESOLVED: The Audit and Governance Committee noted the update above and approved the minutes of the meeting held on 24th May 2021
4. Internal Audit Annual Report and Head of Internal Audit Opinion.
Sharron Blackburn presented the final Head of Audit Opinion and the Annual Report. As members of the Committee had seen the draft audit opinion and annual report at the meeting on 24th May, Sharron highlighted only the key areas. Sharron commented that the Public Sector Internal Audit Standards require a report summarising activity and achievement against plan along with a Head of Internal Audit Opinion in support of the Annual Governance statement. Sharron noted that this report is set within the context of the pandemic and shows the impact on the delivery of the audit plan. However, Sharron was able to present a comprehensive report despite the changes to the plan. Sharron confirmed that the final Head of Audit Opinion provides the opinion of significant assurance.
In terms of delivery of the plan Sharron noted that 26 days had not been delivered and these have been reported to the committee throughout the year and the days will be carried over into the 2021/22 plan as agreed by the committee in March 2021.
Sharron confirmed the changes to the Head of Internal Opinion since the last meeting. Attention was drawn to two final reports that have been issued one of which was high in relation to COVID costs and the other recorded as significant in relation to reducing inequalities monies. A further three reports have been issued in draft; Children’s Continuing Care which has a limited opinion, two further significant opinions in relation to Act as One programme management and the Data Protection and Security Toolkit (DPST).
Sharron confirmed that in relation to the limited assurance report, this has no impact on the bearing of the overall opinion for the year. The report will be finalised during week commencing 7th June 2021 and will be circulated when available.
Sharron confirmed all work relating to 2021 has been completed. The internal audit annual report shows the performance targets have been met with one exception in relation to management responses which have fallen since 2020, however given the current climate this is not seen as significant and has been set in the context of a difficult year.
Bryan Millar asked if in regard to management responses, there is a pattern that can be identified that would cause concern. Sharron stated that as it covered a number of areas, not particular pattern had been identified.
Bryan commented that the reports that received limited assurance are all within similar territories and the issues are linked so this would need to be followed up. Sharron said that it highlighted a lot of work has been completed to strengthen the areas.
Neil Fell commented that this links to our efficiency savings.
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Helen Hirst asked in relation to the Children’s Continuing Healthcare if the audit team is sighted on the work done around the Doncaster Model and those changes. Sharron responded that this has not been previously referred to. The report does not include the detail as there is limited assurance and discussions are still underway. One of the key issues is the policy and procedure the team is working to which is dated 2013 and some of the procedures don’t comply with the national framework and there are aspects of record keeping in relation to support plans which were difficult to trace at times.
Helen commented that at a number of proposals have been made to the CCG senior leadership team (SLT) and Helen would welcome the views of the audit team as they may address the governance issues. Sharron agreed to pick this up with the team at the next meeting (June 2021).
Action: Sharron to review proposals with the CHC team.
Bryan commented that this has been a very difficult year for people and recognises and values the professionalism of those involved.
RESOLVED: The Audit and Governance Committee received and considered the assurance provided in the Internal Audit Annual Report and Head of Internal Audit Opinion 2020/21.
4. Final Accounts
Diane Lawlor highlighted the amendments from the previous meeting. Two changes were made:- to recode and remap the Mental Health Investment Standard Audit Fees and an update to a declaration of interest.
Bryan queried the declaration change and Diane confirmed that a member of the Governing Body had changed their practice during the year and this had not been added to the CCG Register in time to be picked up. Diane suggested that there should be a refresh of the register of interests at the end of the year as well as the current rolling programme of updates.
Bryan thanked the team for all the work that had been undertaken in order to produce the accounts.
Action: Governance Team to note a refresh of the Register of Interests should be undertaken prior to the preparation of accounts.
RESOLVED: The Audit and Governance Committee received and considered the changes to the annual accounts.
6. Final annual report (including annual governance statement)
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Sue Jones presented the key changes made to the Annual Report following the meeting on 24th May 2021. These changes are summarised below: The forward by Dr James Thomas (ps.5 – 7) has been updated as has Helen Hirst Performance Report (ps. 8 -10). Changes were also made to the Access to Care following the comments made around care navigators at the last meeting.(p.24) The constitutional standards and national access targets table have added quarter 4 and national benchmarks (p. 33). In relation to Safeguarding there is a change to title of piece of guidance. (p. 39) Under the Highlights of the year section (p. 50) the closure of the red hubs has been updated. The biographies for David Richardson (page 56) and Ruby Bhatti (p. 57) have been updated. A slight change has been made to section 2.3.5 Constitution (p. 62 - 63) The membership of the Governing Body has been updated to include David Richardson (p. 67) and the governance attendance table has also been updated. The final Head of Internal Audit opinion has now been included (p.107-115) and tables 7, 8 and 12 have been updated as they were originally scanned copies. Following the comment at the last meeting on Primary Care Networks (PCN’s) and Patient Participation Groups (PPGs) (p.20) and these have been included as part of ‘people’ we work with. Full details of their activities have not been included as they are not CCG activity.
Helen highlighted two changes, there is mention of the Council of Representatives which should be removed and under the reference to membership of West Yorkshire Joint Committee there is a formatting issue and names have been mixed up.
Robert Maden asked that in the staff number table, can the split of male/female be checked.
Action: Sue Jones to check staff number table, the Council of Representative reference and the formatting of the West Yorkshire Joint committee table of names.
RESOLVED: The Audit and Governance Committee received and noted the Annual Report.
Helen Hirst presented the Annual Governance Statement. Helen highlighted some key points. This has been a challenging year and the Annual Governance Statement confirmed that financially and operationally the CCG completed what it set out to achieve. From a governance perspective the mechanisms we have around control and governance were challenged in relation to the scope of what we have to do and the way we had to do it and that has set the context.
In terms of the main parts of governance and a control and assurance, the Council achieved its aim to approve the commissioning strategy. This year has seen the Quality Committee and the Finance and Performance Committee come into their own and have stepped up into the more detailed space that Governing Body were not able to due to shifting priorities.
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SLT worked hard to keep a balance of core business such as the weekly focus on children and young people alongside COVID and to ensure we continued with development work as a new SLT. Helen confirmed the robust nature of the SLT in its internal scrutinising function.
The West Yorkshire Joint Committee has operated within its delegated powers and has demonstrated through the report that it has not gone outside those powers.
The statement confirms that the Primary Care Commissioning Committee, Audit and Governance Committee and Remuneration Committee had performed their duties.
From a risk management perspective, the process has worked well. A separate COVID risk register was established to provide assurance to the Governing Body and this has now been integrated into the Corporate Risk Register. The Governing Body received the commissioning assurance framework at the March meeting. This demonstrates that due attention is paid to, covid risks, corporate risks and strategic risks through the Risk Management Framework.
Bryan Millar commented that this was a fair summary of the past year and reflected on what the committees do, provides good assurance and confirmed that Committees do test and challenge.
7. Letter of Representation
Helen Hirst presented the Letter of Representation.
Robert Maden pointed out that the appendix, which includes a technical definition of audit of the letter is not attached to this paper.
Rashpal commented that there is nothing unusual in the letter and External Audit have not asked for anything over and above the standard. Rashpal confirmed there is nothing in the appendix that would stop the approval of the Audit Opinion
RESOLVED: The Audit and Governance Committee approved the Letter of Representative subject to the addition of the appendix.
8. ISA260 Report
Rashpal Khangura highlighted that this report helps us discharge our responsibilities in communicating to those charged with Governance. ISA260 is the international standard for auditors which highlights what those requirements are. This report was prepared within a short timescale and there are some items in red in the report which had not been completed at the time the report was submitted to Audit & Governance. Rashpal confirmed that all of those areas highlighted in red are substantially complete other than some pieces of evidence. Subject to those final elements a clean audit opinion will be issued. The Annual Governance Statement is not audited but External Audit ensure that it is in line with Guidance and there is nothing inconsistent with their knowledge of the organisation. The only element of the annual report audited is the directors remuneration. The rest of the
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report is reviewed to ensure it is in line with requirements. Rashpal confirmed there are no issues to report.
Amy Thomas went through the report highlights and provided an update on those items in red.
On the financial statements – (p.227 of pack), Amy confirmed the only outstanding issue was the expenditure cut off to the end of May as this requires bank statements which do not come out until the end of May. There is also a requirement to review the journals in the window of time that changes are required following audit adjustments.
The finding showed three significant audit risks:- management override of controls and opening balances and expenditure recognition. In terms of opening balances, which relates to the merger of three CCGs there was a need to ensure the ledgers were carried across correctly and there were no issues identified. The management override of controls is an area that the auditing standards require as a significant risk and there has been no issues identified. With regard to expenditure recognition this is again an area where Auditing Standards require a risk and no issues have been identified.
Amy highlighted two recommendations that have been made this year in relation to Journal Segregation of Duty and Declarations of Interests. In regard to Journal Segregation of Duty the audit identified that out of c700 journals, eight had been self approved and a recommendation has been included in the report. The recommendation for Declarations of Interests, as discussed in the annual accounts update, is to update the register of interests prior to the financial year end.
In appendix five in relation audit differences, Amy commented on Prescribing Costs audit differences and pointed out that the CCG is not the only CCG to have an unadjusted audit difference in this area and is related to the timing on receipt of invoice versus when the accrual is added to the accounts.
Rashpal stated that the Value For Money audit (VFM) has not be included as there is a later report that expands on VFM, at the meeting on 24th May this was highlighted as a significant risk however these have now been reviewed and the audit team are comfortable with the arrangements in place.
Rashpal expressed thanks to CCG officers for the support and assistance received.
RESOLVED: The Audit and Governance Committee noted the ISA260 report for information.
9. External Auditors Annual Report
Rashpal explained that this report can only be signed-off when the Audit Opinion is signed however after the Audit Opinion is published, NHS England will contact the CCG around the publication requirements as it provides commentary on VFM however it was deemed appropriate to bring this to the Committee. This report has not been seen before by the Committee but is now a requirement of the new Code of Practice released by the National Audit Office.
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Bryan clarified that the CCG will need to publish the report and Rashpal confirmed the report should be made available to the public and therefore should be added to the website. Guidance will be sent about how and when and this guidance will be forwarded to the CCG. Robert Maden confirmed there is a checklist which highlights those requirements for publication.
Rashpal highlighted the report summary on p.252 of the meeting pack and went onto p. 256 focussing on Value for Money. This work is now concluded following an understanding of 2021/22 funding. Guidance around the first half of the year (H1) was published late which impacted on the risk assessment. In relation to financial sustainability the audit looked at the CCG response to requirements for H1 and following challenge to some of the assumptions are comfortable with the reasoning around where the CCG have moved away from the national assumptions. The Audit provided assurance of the arrangements in place.
The report considers the governance arrangements and the arrangements in place around improving economy, efficiency and effectiveness. Rashpal concluded that the Audit Opinion confirms no significant weaknesses in the CCG arrangements.
Rashpal confirmed that when all areas of work complete the CCG will receive final signed copies of the report and audit opinion.
Bryan Millar commented, on behalf of the Committee, on the work of the team and gave his appreciation of the mature way the dialogue around the process was conducted. Robert Maden commented on how well the regular updates worked.
RESOLVED: The Audit and Governance Committee noted the External Audit Annual report for assurance - subject to final changes.
Susan Hall joined the meeting.
10. Data Protection Officer (DPO) Annual Report
Susan Hall presented the DPO report. Susan commented that this has been a quiet year having no major incidents, no direct contact has been made with the Information Commissioners Office (ICO) and no complaints have been received from service users about the CCG’s data protection practices.
It has also been a busy year due to the pandemic with some rules and precautions being set aside. There have been changes in legislation and the ICO took a pragmatic approach in light of the pressure on the NHS and the priority being the delivery of care, nonetheless organisations remained accountable for the use of data.
The activities highlighted in the report include involvement in the records management group and also representing the CCG on the Information Governance work stream of the Bradford Digital programme.
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Bryan commented that the report summarised the activities and forward plans. Bryan also highlighted the checklist at the back of the report which gave assurance to the Committee.
Neil Fell commented that there is a head of steam building around opting out of data sharing and the timescale of 23 June. Neil asked how the CCG was affected. Susan responded that this relates particularly to the sharing of GP data and the creation of a large data bank, which has proved particularly useful during COVID. Susan confirmed there has been some push back in the Data Protection Community regarding the timescale. Susan referred to the Care.Data issue where the introduction of this was not communicated effectively to patients. Susan confirmed that this does not directly affect the CCG as it is not our data being shared.
Helen Hirst has also raised this issue internally as no guidance has been received and communication information has been requested to support delivery. Helen clarified that the 23rd June date is not a deadline to opt out, rather it is the deadline by which you can opt out.
Susan offered to share information she had received following the update.
Action: Susan to send update information to the Committee.
Bryan thanked Susan for the report and for her work throughout the year.
RESOLVED: The Audit and Governance Committee noted the DPO annual report for assurance.
11. Annual Report and Accounts
Bryan sought clarification of the process following this Committee’s approval of the accounts. Robert confirmed that once the final outstanding audit items have been completed, with the expectation that there will no issues raised, the accounts will be signed off by the external audit team and then the annual report and letter of representation will be signed by the Chief Officer prior to submission to NHS England by 9.00am on 15th June 2021. The final stage is formal reporting to the Governing Body that the Audit and Governance Committee has approved all documents on their behalf.
Helen Hirst updated that the annual report and accounts will also be presented at the Annual General Meeting on 28th July.
Bryan expressed his thanks to all those involved in the production of the accounts and the annual report.
RESOLVED: The Audit and Governance Committee, subject to no issues being raised in the final audit report, approved the final accounts and the annual report.
12. Any Other Business
Sue Baxter raised an item relating to the establishment of the ICP and noted that the Governance work stream is being led by Paul Hogg and Paul also links in with the West
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Yorkshire work stream around the development of the ICS. Discussions have been held on the remainder of the year and shadow arrangements. A proposal is to be submitted to the Audit and Governance Committee in relation to tapering down CCG governance arrangements.
Sue also noted that there will be legacy requirements such as the annual report and accounts which will be received by the new organisation. Rashpal supported the reference to the legacy requirements and requested regular communication when changes occur.
Bryan commented that there is need to be clear around the approval and assurance route. Sue confirmed that the proposal would be a measured approach and will ensure that all duties are discharged. Once the approach is tested with the Audit and Governance Committee out this will be submitted to Governing Body for approval.
Robert confirmed the need to work closely with the ICS work streams for example the financial work stream will pick up how the annual accounts will be dealt with.
Bryan informed those in attendance that there has been a Programme Board established within the CCG which comprises the four members of the Audit and Governance Committee and the proposal will also been seen there.
Liz Allen expressed her thanks to Sue Baxter who took up her role as Strategic Head of Assurance this year and this has been a challenging year for the Corporate Governance Team and Liz acknowledged Sue’s leadership of the team over the last 12 months.
Bryan endorsed Liz’s comments and added as chair of the Audit and Governance Committee and a participant in other committees, he has received excellent support with the corporate governance team being flexible in their approach and proactive in maintaining contact.
13. Date and time of next meeting
The date of the next meeting was confirmed: 5th July 13.00 – 15.30 via Zoom – details to follow.
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Minutes of the Primary Care Commissioning Committee
Tuesday 9th March 2021
Zoom meeting
Present Representing Ruby Bhatti (Chair) Lay Member for Primary Care Commissioning CCG Dr Louise Clarke (non-voting) Strategic Clinical Director of Strategy and Planning (GP) CCG Neil Fell Lay Member for Finance & Performance CCG Angie Clegg Registered Nurse CCG Robert Maden Chief Finance Officer CCG Bryan Millar Lay Member for Audit & Governance CCG David Richardson Lay Member for Quality CCG John Young Secondary Care Consultant CCG Helen Hirst Chief Officer CCG Dr James Thomas Clinical Chair
In attendance Neil Coulter Senior Primary Care Manager NHSE Ashley Green CEO Healthwatch NY Helen Rushworth Manager Healthwatch Bradford Sue Baxter Strategic Head of Assurance CCG Dr Steve Patterson YORLMC Ltd Chair (GP) LMC Dr Val Wilson YORLMC Ltd Liaison LMC Karen Stothers Senior Head of Strategy, Change and Delivery CCG John Hartley Senior Head of Quality Improvement CCG Debbie Oxley Head of Strategy Change and Delivery CCG Gill Paxton Senior Head of Quality Improvement (representing CCG Michelle Turner)
Apologies Ali Jan Haider Strategic Director of Keeping Well at Home CCG Ashley Green CEO Healthwatch NY
Members of the public: 0
1. Welcome and Apologies
Ruby Bhatti, Chair of the Primary Care Commissioning Committee (PCCC), welcomed everyone to the meeting of the NHS Bradford District and Craven (BDC) PCCC. Apologies were noted from Ali Jan Haider, Strategic Director of Keeping Well at Home and Ashley Green, CEO of Healthwatch NY.
2. Declarations of Interest
No declarations of interest were raised at this point in the agenda.
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3. Minutes of the meeting held on 12th January 2021 and action log
The minutes of the meeting held on 12th January 2021 were agreed to be a correct record by the members of the Bradford District and Craven (BD&C) CCG PCCC. There were no matters arising.
RESOLVED: The Primary Care Commissioning Committee approved the minutes of the 12 January 2021.
4. Primary Medical Care: Service Provision during Covid 19
Karen presented the paper which provided an overview of the national support for general practices and looks at the national statement in relation to contractual requirements for 2021/22. The paper also provided a snapshot of the COVID Vaccination Programme and a summary of current practice site closures.
Karen stated that the Pulse Oximetry programme model is going well and there are plans to expand funding into the new year. In relation to LD and the annual health checks, there is a requirement that CCGs reach a national target of 67%, Karen updated that Bradford stands at 73%.
Karen provided highlights in relation to the extended access scheme this service was due to go into the Network DES as at 1st April 2021. Nationally it has been agreed that the existing commitment to providers will remain in place for the coming year. Moving forward conversations will need to take place with primary care networks relating to extended contracts.
In relation to 2021 Karen noted that this includes an explicit definition of the ‘core digital offer’ and what is expected of general practice for example total triage and on-line consultations and the need to ensure these remain in place. We are currently undertaking a scoping into disparity into the website offer from practices. There is a lot of support in addition to digital funding to support this work.
Karen highlighted the vaccination programme and the work of the Primary Care Network (PCN). It is important to note that this programme is currently only in place until August and only for the over 50s population.
In terms of local outbreaks the paper presented the picture as at 25th February 2021. We are seeing some outbreaks in practices where staff are not taking up the vaccine. We are undertaking some work to promote the vaccine with practice staff.
Karen summarised the position in relation to site closures and noted a number of these are small premises and therefore have identified some issues in relation to the management of patient flow, these are branch sites and Karen emphasised surgeries are still open.
Neil Fell asked if the issue of funding for the pulse oximetry had been resolved. Karen responded that within the expanded capacity fund the CCG were given £1.57m locally and in agreement with LMC £50,000 was taken from that funding to support delivery of pulse service. Other funding streams have supported this piece of work.
In relation to site closures Neil asked if there had been any feedback on how patients have been affected. Karen commented that some minimal complaints have been received in relation to how practices communicate and we have been working with sites on communication methods.
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RESOLVED: the Primary Care Commissioning Committee:
1. Noted the overview of the national agreement in supporting general practice. 2. Noted the contractual requirements for 2021-22. 3. Noted the latest COVID outbreak T & T practice staff position. 4. Noted the update on site closures.
5. Contract Assurance and Performance Report
Debbie Oxley presented the paper which provided a summary of contracting quality assurance, a review of guidance and a summary of the discussion at the Contracts Assurance Group (CAG).
Debbie informed the committee that the Contract and QA process remains suspended until April 2021, Work is underway look at more efficient ways of working both in GP Practices and within the CCG.
Debbie noted that Farrow Medical Practice remains under enhanced surveillance. A visit was scheduled in January but has been postponed to enable the practice to support the rollout of the vaccination programme.
In relation to those practices serving the student population, NHS E data shows there has been a significant reduction in student registrations since the start of the 2021 academic year. There is a risk that reduced registrations could destabilise service delivery and potentially impact on practice viability. In Bradford District and Craven CCG there is only one university practice, Bradford Student Health. They have only seen a small reduction in registrations and the practice have confirmed there has been no financial impact. Debbie stated that the available funding is for this year only. If there is a significant impact on registrations the guidance suggests that funding as an atypical practice be considered.
CQC routine inspections remain suspended. The CQC have Introduced a transitional regulatory approach which is done remotely. The CQC have confirmed they will only inspect a practice where they have real concerns around the safety and quality of care.
Debbie updated the committee on the Contracts Assurance Group (CAG).
Bevan Healthcare CIC does not serve a typical practice population and not all QOF indicators are relevant in improving outcomes for this group of patients. Therefore the CCG agrees local indicators. The local indicators are being worked up and will be brought back to the Group for consideration.
SAS (Safe Haven Service) Procurement Update. The Group were informed that due to the pressure in delivering the Covid vaccine the submission date for bidders was extended to 31st March 2021. Local Care Direct, the existing provider has agreed to extend the contract to 30/09/2021 to allow for the procurement to proceed.
Network DES (ARRS Scheme). The CAG had noted that the electronic claims for additional roles reimbursement portal is now live however the CCG requested that they commenced using the portal from the new financial year (2021) and NHS England have approved this.
A Home Visiting protocol has been developed which provides best practice guidance during Covid was shared with the Group then sent to practices for reference.
The PCN Estate Commissioner Guide looks at the changing estate landscape as the PCNs expand their additional roles workforce, consideration need to be given to future estate’s needs. NHS England has launched guidance to support the consideration of applications for repurposed, new or expanded estates. Applications will be considered in line with the CCGs estates strategy, ensuring that any void space was utilised.
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There has been an update to the NHS England Primary Medical Care Policy and Guidance Manual and this includes the latest GP contractual changes. Local policies will be reviewed following the publication of the update.
Debbie highlighted, for information only, a summary of primary care risk within the corporate risk register and this was included in the paper.
RESOLVED: The Primary Care Commissioning Committee noted the paper and: 1. Noted the actions taken by the Primary Care Contracting and Quality Team in the management of the contract and quality assurance process. 2. Noted the review of Bradford Student Health Medical Practice 3. Supported the recommendation that the current contract to provide a Safe Haven Service be extended to 30th September 2021. 4. Noted the primary care risks.
6. Grange Park Surgery – Domiciliary Phlebotomy
Karen noted this paper was for information only in relation to domiciliary phlebotomy services delivered in general practice. Karen highlighted that the PCCC is required under the terms of reference to ensure its management of the function in accordance with the Delegation Agreement. These services are not resourced from the CCG primary care delegated funds, they are contracted through an NHS standard community contract and are therefore not in the remit of this committee. The services have an overlap with PMS Premium funded services commissioned in general practice therefore important to note how this service is being contracted. This paper refers to Grange Park Surgery and allowing them to provide domiciliary phlebotomy for their own registered patients. Previously other practices, Addingham, IG Medical and Ilkley and Wharfedale have been commissioned to provide this service however this proposal would allow Grange Park Surgery to provide this service directly to their patients.
Karen highlighted that if these were new services, the Governing Body would be sighted on this proposal however this is not new, this is expanding provision. There is a view that there is a need to look at the Contracts Assurance Group Terms of References to give the Group the autonomy to approve some primary care contract changes.
Bryan Millar acknowledged that this was not in the remit of this committee however he believed it was important to look at where these issues were reviewed. Although it has been stated it will not cost additional money Bryan questioned if this service was not previously provided within Grange Park then this would require additional funding. Bryan also questioned if the service was across the whole of the Wharfe Valley and would postcode rationing be taking place. Bryan also asked around prioritisation against investment and suggested there is a need to have a conversation around where these requests are approved.
Karen agreed and any decisions should make links with the Act as One and Access programme.. In this case phlebotomy is a GP function, as locally this is seen as an enhanced service to the core contract. Action: Karen suggested that a review of phlebotomy services is required across Airedale, Wharfedale and Craven Locality.
Bryan Millar asked for clarification on how these decisions would be made and sought the Committee views. James Thomas stated that a discussion would be best placed within the CCG and the matrix working across the hubs then via Finance, back into the Place discussions.
Bryan Millar suggested that this issue be reported back to the Governing Body to gain their view on how and where we make these decisions. Ruby Bhatti agreed to seek clarification. Action: Ruby to take this item to Governing Body
Neil Fell sought clarity on the activity and if this would normally be built into the community contract but as it is not functioning that far is this a geographical issue. Karen explained that the history of the
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387 388 commissioning is not fully known however previously we have commissioned Addingham, IG Medical and Ilkley and Wharfedale to provide this service.
RESOLVED: The Primary Care Commissioning Committee noted the paper. Ruby Bhatti agreed to raise the issue of where discussion in relation to enhanced services will take place.
7. Westcliffe Care UK Ltd (North Street) – Diabetes L2.
Karen commented that this issue was similar to agenda Item 6. The provision of Level 2 diabetic services to the population was provided from Airedale Trust. The Trust had stated that they no longer have capacity to provide this service and a contract variation has been put in place to enable Westcliffe Care UK to provide this service to their population at North Street. This will be reviewed as part of the wider Diabetes Review.
James Thomas stated there was some alignment with diabetes transformational programme. Karen commented that depending on the service was to be commissioned following the review, there could be an opportunity to look at provision at network level (being under the Network DES) Should this review move the service into the Network DES then this committee would need to consider the proposal under the delegated commissioning responsibilities.
RESOLVED: The Primary Care Commissioning Committee noted the paper.
8. PCCC Terms of Reference Review and Effectiveness Review
Ruby Bhatti presented the paper which looked to review the effectiveness of this committee and to look at any potential changes that could be undertaken to strengthen the operation of the committee.
Ruby asked member of the committee key questions: if there were any issued to be raised if members were happy with on line arrangements if there were any suggested changes
No issues were raised by members of the Committee
John Young commented that the papers received were very clear and thanked Karen and colleagues on the clarity.
Ruby sought approval of the Terms of Reference for the Committee. This was agreed.
RESOLVED: The Primary Care Commissioning Committee noted the paper. The Committee approved the Terms of Reference.
9. Key Messages for the Governing Body
No additional items were raised.
10. Date and Time of Next Meeting
The next meeting of the Bradford District and Craven CCG PCCC will take place on Tuesday 11th May 10:30am to 12:45.
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NHS Bradford District & Craven CCG
Minutes of the Finance and Performance Committee Meeting Thursday 1st April 2021, 10.30 – 12.30, via Zoom
Present: Neil Fell (Chair) Lay Member for Finance BD&C CCG & Performance Bryan Millar Lay Member for Audit BD&C CCG & Governance Robert Maden Chief Finance Officer BD&C CCG
In Attendance Chris Balson Senior Head of Strategy BD&C CCG Change Delivery Stacey Fleming Senior Governance & BD&C CCG (for agenda item 9 only) Resilience Manager
Walter O’Neill Strategic Head of BD&C CCG Keeping Well Kerry Weir Associate Director, BD&C CCG Population Health & Wellbeing Andrew Creighton (minutes) Team Administrator, BD&C CCG Finance and Digital Team
Apologies Sarah Dick Head of Corporate BD&C CCG Governance Louise Clarke Strategic Clinical BD&C CCG Director Strategy & Planning Amy Paffett Strategic Head of BD&C CCG Finance
1. Apologies Apologies were noted as above.
2. Declarations of Interest There were no declarations of interest. The register of interests records all interests declared and is available at: www.bradforddistrictandcravenccg.
3. Minutes of the Meeting held on 4th March 2021. The minutes of the Finance and Performance Committee meeting held on the 4th March 2021 were agreed to be a fair representation of the meeting.
4. Action Log • Primary Care Rebate Schemes (PCRS) for Prescribing: a list of the schemes in operation, who they were with, and approximate values, had been circulated with the papers for the
389 390 present meeting. • Annual Report - Annual Governance Statements: Finance & Performance Committee Annual Governance Statement for the Annual Report had been e-mailed to Stacey Fleming.
5. Performance Report The report was received and Kerry Weir briefed the meeting. Key points to note:
• Bradford Teaching Hospitals Foundation Trust (BTHFT) saw A&E attendances increased in line with pre-Covid levels, whilst Airedale Hospital Foundation Trust (AHFT) attendances decreased slightly during February. Both Trusts performed well in terms of 4 hour access. • 18 week performance continues to be a challenge. Elective capacity has been significantly impacted by Covid (lack of Theatre space), and 52+ week breaches are increasing with 19 BTHFT patients having now waited >104 weeks. It was noted that 2 year waits are now on the dashboard. Some of the lower priority (P1 &P2) work is being transferred to the independent sector. • 18 weeks also a challenge for Bradford District Care Foundation Trust. The community dental service has resumed taking referrals, but the waiting list is growing. • Diagnostic performance continues to improve, with both Trusts have increased capacity and are also making use of Independent Sector capacity. • Cancer services continue to be maintained and there has started to be a reduction in over 62 day waiters. • Increased referral rates are putting pressure on mental health services including Child and Adolescent Mental Health Service (CAMHS), Perinatal Mental Health and Children and Young People Eating Disorder services and inpatient mental health acuity and be occupancy remains high. • Delivery of Learning Disability (LD) Annual Health Checks (AHCs) is currently forecast to be above our recovery plan at 72% for 2020/21. Delivery of AHCs for people with Severe Mental Illness (SMI), however, remains a challenge. • Continuing Health Care (CHC) assessment backlog has 52 cases remaining (20 cases behind clearance trajectory). It is projected that the backlog will be cleared in early May. • The number of daily reported cases of Covid has continued to fall. • The Covid vaccination programme continues. As of 22nd March over 233k first vaccinations had been given, and over 17,000 second vaccinations. • A Community Vaccination Centre is being established at Airedale General Hospital. • Work is ongoing to mitigate any inequalities arising from the vaccination delivery programme. KW noted the degree of central control being imposed.
The Finance and Performance Committee noted the update.
6. Contracting Report The report was received and Chris Balson briefed the meeting. Key points to note: • Most positions were unchanged • There were some changes and updates to Independent Sector positions (Yorkshire Clinic and Yorkshire Eye Hospital). • Yorkshire Eye: there had been a 3 month extension to the framework put in place in January. This expired yesterday. A further 3 month extension of the national contract has now been put in place. • Yorkshire Clinic: A 6 month contract plan had been signed with the YC yesterday. The acute Trusts will lift and shift a lot of P3 & P4 activity to the YC (YC lacks the ICU facilities to take more complex cases), and it will also be used for to address the diagnostic waiting list. It was noted that there was an element of collective system risk around managing the extra activity financially, and some discussion around how to fairly represent the efficiency levels of the Trusts, as they will be left with the more complex cases. The 2021/22 tariff had not yet been finalised. It was noted that the system had been working well together and supporting each other, and that the YC had been fully on board in working almost as a system partner.
390 391 • Bradford District Care NHS Foundation Trust Contract and Quality Board meetings and reporting remained suspended for Covid. For the duration, monitoring is being conducted more informally through the System F&P and System Quality Committee members. Action Point: Minutes of the System F&P Committee to be received at this meeting. It was noted that reporting was very light touch. Action Point: NF & RM to discuss what reporting can be currently expected, and what needs to be seen where. The meeting received and noted the report and contract positions.
7. Finance Report The report was received, and Robert Maden briefed the meeting. Key Points to note: • Some in-month movement on some lines • A break even performance forecast (the only risk is around prescribing) • Some movement within prescribing. The drift upward in forecast outturn spend has been offset by predicted budget underspends elsewhere. It is unclear what is driving the upward drift. • A small risk to carry over to 21/22 around the backlog of Scheme 1 assessments. It is unlikely that the cost will be recovered. • A significant increase in Community Equipment spend. Formerly charged against the capital budget by the Council. We will be making a contribution to offset council capital costs. RM explained the legitimacy of doing so from an audit scrutiny point of view. • The Trusts are on block contracts and are in a healthy position financially for 2020/21 (because of reduced elective activity due to Covid), and performance is expected to be at least in line with plan. The Report was noted.
8. Operational and Financial Planning Update for 2021/22. • Robert Maden circulated a slide presentation of a Financial Plan update by e-mail. • It covered the current position, the approach for 21/22, and the timetable for submission (it was noted that this was very tight). • West Yorkshire organisational funding envelopes had been agreed. It remained to be seen how this would fit with nationally calculated ICS envelopes. • Financial H1 envelopes were being rolled forward from 20/21 with some adjustments. • It was considered that the half-year national planning requirements were quite challenging in terms of what was being asked. This together with the lateness of the planning guidance presented a significant challenge in terms of producing the financial plan for H1 2021/22. • A first draft is to be submitted by 16th April, with ICS submission to NHSE due on 6th May. Action Point: RM to convene an extra, 1 item agenda, Finance and Performance meeting on Friday 30 April, 10.00 – 11.30 for internal CCG sign off. Action Point: RM to seek a mandate for such sign-off from Governing Body next week The meeting noted the presentation.
9. Corporate and COVID Risk Register The meeting received the report and was briefed by Stacey Fleming. It was noted that this was the first report since the Corporate and Covid risk registers had merged. Key points to note: • There were no FPC risks classed as ‘critical’ (scoring 20 or 25). • There were six FPC risks classed as ‘serious’ (scoring 15 or 16) and two risks that align to both FPC and QC classed as ‘serious’. • The most serious rated risk, around the underlying financial position was rolling forward into 21/22. • One new risk (1735) had been added around the possible risk to IT system performance following the imminent new release of functionality on SystmOne. It now seems that this is unlikely to materialise • Action Point: SF to review inclusion. • It was noted that there had been discussion at SLT around adding a holding risk for the next cycle around the transition to ICS, and the potential effect on business as usual. A
391 392 risk owner would have to be identified, and a separate risk register may be merited. The meeting reviewed and accepted the report.
10. Issues to highlight to SLT & GB • RM to seek mandate from Governing Body for planning submission sign off
11. Any Other Business None 12. Date and Time of Next Meeting The next meeting will be held on Thursday 6th May 2021, 11am – 1pm, via Zoom.
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Minutes of the Finance and Performance Committee Meeting Friday 30th April 2021, 10.00am – 11.30am, via Zoom
Present: Neil Fell (Chair) Lay Member for Finance BD&C CCG & Performance Bryan Millar Lay Member for Audit BD&C CCG & Governance Robert Maden Chief Finance Officer BD&C CCG
In Attendance Chris Balson Senior Head of Strategy BD&C CCG Change Delivery Walter O’Neill Strategic Head of Keeping BD&C CCG Well Amy Paffett Strategic Head of Finance BD&C CCG Sharon Wood (minutes) PA to Chief Finance BD&C CCG Officer
Apologies Louise Clarke Strategic Clinical Director BD&C CCG Strategy & Planning Kerry Weir Associate Director, BD&C CCG Population Health & Wellbeing
1. Apologies Apologies were noted as above. 2. Financial Plan H1 2021/22 Robert Maden presented the financial plan H1 2021/22 to the Committee. Key points to note were: No uplift to running cost allocations. Additional funding for elective recovery and mental health recovery (national £1bn and £0.5bn). Hospital Discharge Scheme (Discharge to Assess) funding continues in H1. No access to historic surpluses. Prescribing uplift reflects local growth seen over 2020/21. Continuing care uplift reflects an overall fee increase of 4.5% and activity growth of 1.5%. A4C pay award based on a 2% national settlement (not finalised yet). Some additional resource may be received for this, but not for the running cost element. The H2 underlying deficit has increased from the opening deficit of £2.8m to £4m due mainly to higher recurrent costs in prescribing and mental health. The increase in the underlying deficit was funded from non-recurrent underspends in 2020/21, including £600k of surplus prior year accruals. H1 Plan shows a deficit of £5.5m after additional funding of £2.3m from the Elective Recovery Fund. Excluding ERF funding, there is a Plan deficit of £7.8m
Financial risks Main Risks Savings shortfall (currently unidentified) £1,454k Activity risk (mainly Continuing Healthcare) £1,068k
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Fully offset by use of Contingency Reserves - £2,522k (Expect to generate in-year non-recurrent savings to help manage the position) Additional Savings to Achieve a Balanced Position - £5,517k
Collective Agreement to Manage Through Place Based Risk Sharing - £5,517k (Local Trusts have balanced Plans for H1) Receipt of Full Elective Recovery Funding depends on performance across the ICS which may result in less than 100% of the expected £2,300k funding being received.
Application of WY&H ICS ERF risk sharing principles to maximise recovery where ERF baselines exceeded.
Following the presentation the following was raised from the committee members:
Neil noted in terms of Hospital Discharge the assessment period before the CCG becomes financially responsible reduces from 6 to 4 weeks. Robert confirmed the 4 weeks fits in with the national framework timescales for carrying out the full CHC review. They have allocated 6 weeks to allow more time as there are more pressures in the system and they anticipate this will return to a normal process in Q2.
Neil asked in terms of rollout of the 2 hour crisis community response at home is this something the CCG needs to set up from new and is it the Care Trust the responsible provider. Walter confirmed it is a combination of new and integrating existing services and what will be required is a central point of access linking in with 111 and YAS ensuring people get a response to an emergency rather than an ambulance taking them to A&E.
Bryan asked a question around the Elective Recovery fund. There is £1bn nationally and presumed there is a level of funding activity in the baseline for the Trusts so do they pick up that elective activity to the maximum level which will be £10M for the Bradford place that is available over and beyond what they are building in for increased activity. In previous years would have been a contract activity pressure and an element of that will be managed by this if activity goes beyond the baseline levels if that pot is available. Robert confirmed it is a national pot so what you get depends on what you do, and the baseline level is 19/20 activity which some providers may struggle to reach. Chris confirmed the Independent Sector are going to achieve their 19/20 levels but not much beyond that. Some of them across West Yorkshire have estimations they are going to achieve by double what they did in 19/20 which is a growth over estimation of what they can do. The Yorkshire Clinic has been very realistic about that and their plan is a 19/20 level and no more. Robert confirmed it does avoid a cost pressure should you do really well and get activity coming through as in theory you can continue to access the fund as you are addressing the backlog they want you to address.
Neil highlighted the recovery threshold of 85% remains as in the original reset letter, but in terms of how the activity is now allocated by priority level does it complicate performance measurement around which provider is reaching what level. Robert confirmed the baseline is a financial value baseline ensuring you do what you need to do in the right order. Locally there will be a process that will bring together the Bradford place performance that feeds into the ICS so they can understand how that risk management arrangement of the ICS plays out across and back into Bradford. Everyone is aiming to meet the thresholds and exceed them but until you get the activity coming through you don’t know what the position is going to be and it is a risk but is a system risk and there are a set of system arrangements to deal with that.
Bryan highlighted in terms of the prescribing costs 3.5% and 0.6% and putting those into budgets locally and is there an argument by doing that the CCG are accepting that level of cost pressure and making a decision to fund something that they are not funded for and an alternative might have been to put a lower amount or nothing into those budgets to create some CIP requirement. Robert confirmed you could and some CCGs have either taken that approach or something closer to it as they have put a lower uplift in. For H1 the realities are that even if you put the lower figure in there’s a risk it might increase if you don’t do something to contain costs and the capacity to do
396 397 something is not quite there in terms of implementing QIPP schemes. The CCG will be continuing to use PresQIPP and OptimiseRX prescribing support systems to help people prescribe costs effectively. Beyond that unless you have capacity to implement specific schemes it is difficult to generate cost savings. Neil asked whether the other CCGs in the patch have taken a similar approach. Robert confirmed there are some CCGs who have applied the uplifts in the national guidance and are flagging a risk in the plan. Amy confirmed one CCG in the ICS has assumed a higher level of growth than the plan, but the others have put in at the plan assumption. It is fair to say that they identify risk as all recognise annual growth between 3 – 4%.
Bryan asked if the CCG were funding something re-currently from non-current resources. Robert confirmed the funding basis is different to the normal funding basis, but as a minimum there are some covid resources in there which will fall away that are funding recurrent costs and for the CCG this is significant, for e.g. as part of the funding envelope they got a share of those costs which amounted to £5M and their covid spend is just over £1M in the 21/22 plan. The impact of this may well be offset though by returning to normal revenue resource growth levels.
Bryan highlighted this position will be the starting position as an organisation in 21/22. What is passed on to a successor organisation could look different and there is a need to track that and map it out.
Bryan highlighted the H2 underlying deficit of £4M was the underlying outturn at the end of the 2nd half of 2021 but the CCG will have managed to mitigate that for various reasons in 2021. Robert confirmed the CCG managed this through other non-recurrent underspends in the main.
Bryan highlighted there is an element of local growth vs national uplift that is discretionary, but that the impact of this was relatively low considering the difference in some of the uplifts applied. Other items were effectively mandated in the planning guidance, leaving development spend as the remaining discretionary item. Robert confirmed it does in the main relate to RIC schemes which have slipped, and whilst in theory it might be possible to stop some of these, we were not proposing to do so as they were part of the original agreed programme.
Bryan highlighted if you took H1 plan deficit before ERS of £7.8M and took the national planning uplifts into their budgets you would only take £1.1M off that starting problem.
Bryan highlighted the £5.5M in the plan which will be submitted goes into a savings row and is the only difference in presentation, and are they saying that as this plays out during the year the Trusts would expect to see a level of activity related underspend as happened last year with resource being played back to the CCG. Robert confirmed that that was the expectation and appropriate contract variations would be agreed with the CCG to reflect this.
Neil asked in terms of this approach for 2021 have the auditors questioned this approach. Robert confirmed in terms of 2021 the CCG have a rationale to support the contract variations. Therefore, we wouldn’t expect the auditors to challenge this and would have to be the same in 21/22.
F&P Committee Considerations Is the budget setting basis described reasonable? Bryan confirmed the budget setting basis described is reasonable, they may have been overly generous around some of the uplifts rather than the national position, but given the scale of it it’s a little more than a foot note in terms of the overall end point.
Do we have sufficient assurance that the overall savings target is manageable at Place? Bryan felt the CCG didn’t have sufficient assurance that the overall savings target is manageable at place, but not sure they could get any more than they’ve got which is a risk. In theory they could approve a budget that is in balance, but carries an acknowledged risk that is reliant on the action of other Place partners to help resolve. As there is no realistic alternative proposition, in the circumstances it seems a balanced and reasonable approach.
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Neil agreed, the CCG is dependent on there being no adverse circumstances affecting the other place partners’ finances. If financial pressures arise over the next 6 or 12 months they have first call on their “contract resource”. Any financial pressures will hit their books first and reduce capacity to contribute to the place position. The CCG have to take their ability to contribute on trust as they don’t necessarily know all their financial circumstances, other than they are planning to achieve balance.
Does the Committee feel able to recommend the H1, 2021/22 financial plan for approval by the Governing Body? The committee were happy to recommend the H1, 2021/22 financial plan for approval by the Governing Body and suggested it was presented in the same way as presented to this Committee.
Next Steps Paper prepared for Governing Body 2nd May Final Financial Plan Submission to ICS 3rd May Submission of ICS Financial Plan to NHSE 6th May Governing Body Approval 11th May 3. Date and Time of Next Meeting The next meeting will be held on Thursday 6th May 2021, 11.00am – 1pm, via Zoom. Apologies from Louise Clarke.
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NHS Bradford District & Craven CCG
Minutes of the Finance and Performance Committee Meeting Thursday 6th May 2021, 11.00am – 1pm, via Zoom
Present: Neil Fell (Chair) Lay Member for Finance BD&C CCG & Performance Bryan Millar Lay Member for Audit BD&C CCG & Governance Robert Maden Chief Finance Officer BD&C CCG
In Attendance Chris Balson Senior Head of Strategy BD&C CCG Change Delivery Walter O’Neill Strategic Head of Keeping BD&C CCG Well Amy Paffett Strategic Head of Finance BD&C CCG Kerry Weir Associate Director, BD&C CCG Population Health & Wellbeing Sharon Wood (minutes) PA to Chief Finance BD&C CCG Officer
Apologies Louise Clarke Strategic Clinical Director BD&C CCG Strategy & Planning
1. Apologies Apologies were noted as above. 2. Declarations of Interest There were no declarations of interest. The register of interests records all interests declared and is available at: www.bradforddistrictandcravenccg. 3. Minutes of the Meeting held on 30th April & 1st April. The minutes of the Finance and Performance Committee meeting held on the 30th April and the 1st April 2021 were agreed to be an accurate record. 4. Action Log Minutes of the System F&P Committee to be received at this meeting. - The minutes are on the agenda. Action complete.
NF & RM to discuss what (BDCT) reporting can be currently expected, and what needs to be seen where. – Neil and Robert had a discussion around an increasing level or lack of contracting, performance information from the Care Trust. The concern was that there was insufficient information available to monitor the contract. The committee were also made aware that there was limited information being reported to the BDCT board also and this was felt to be a risk. The emergence of pressures in relation to the 18 weeks dental issues and the ongoing pressures on out of area referrals were also of concern. It was agreed that Robert would speak to the Care Trust to get more information and link to the Quality Committee. ACTION: Robert
Robert highlighted in terms of the Care Trust there is a reference in the contracting report
399 400 saying things are starting to flow again that was paused and reference to a 2021 report where the CCG will see some of the missing information and there is a general sense things are starting to turn around. Neil noted in terms of this action, the Committee accepted they have made some progress with it and would wait for the restored information flows to come through. The specific points of concern will be picked up separately. Action complete.
Bryan highlighted it would be useful to think about the context of today’s agenda, when looking at the standing agenda items the F&P Committee have had for a number of years increasingly it is becoming a scorecard to review and the real business and activity that needs an overview is contained largely in the System F&P minutes. Need to think about changing the emphasis for future meetings as what passes for decisions are the ones that are informally delegated to Robert to take forward into the system wide group and work through with Finance Directors.
Robert confirmed a piece of work has started to look at this recognising the move to an ICP board and structure reports in that way provide assurance back into the appropriate committees and very much along the same lines of thinking in terms of emphasis and style of reports which is being developed over the next 3 months and can share some examples with this committee. Bryan highlighted the need to think about the assurance and governance aspects in terms of other committees around the decision making in the wider ICP framework.
RM to convene an extra, 1 item agenda, Finance and Performance meeting on Friday 30 April, 10.00 – 11.30 for internal CCG sign off of the H1 – 2021/22 Financial Plan. – A meeting was held 30th April. Action complete.
RM to seek a mandate for such sign-off from Governing Body next week. – Action complete. 5. Performance Report Kerry Weir gave an update.
Key points to note are: • Bradford Teaching Hospitals Foundation Trust (BTHFT) saw A&E attendances increase in line with pre-Covid levels, and Airedale Hospital Foundation Trust (AHFT) saw attendances increase to levels not seen since the start of 2020, with acuity and conversion to admission rates in line with patterns typically seen at this time year; • 18 week performance continues to be a challenge as, although outpatient activity continues, elective capacity has been significantly impacted by Covid. As a result 52+ week breaches are increasing at AHFT. Due to the moving of patients to the independent sector, BTHFT have seen a decrease in those waiting over 40 weeks and a reduction to 16 from 21 in February of those waiting >104 weeks; • Acute trust capacity continues to impact upon Bradford District Care Foundation Trust’s (BDCFT’s) community dental service, with a growing number of patients on the waiting list and 103 patients now >52 weeks; • Diagnostic performance continues to improve, with both Trusts making use of independent sector capacity; • Cancer services continue to be maintained and there is now starting to be a reduction in those who have already waited over 62 days; • Increased referral rates continue to put pressure on some community mental health services, particularly CAMHs and business continuity plans have been activated, with capacity being drawn from broader Multi-Disciplinary teams (MDTs) to support allocation of duty, releasing capacity to offer 1st & 2nd appointments.
400 401 • The number of daily reported cases of Covid has continued to fall; • Delivery of the Covid vaccination programme continues and as of 22nd March over 282k first vaccinations have been given as well as over 100,000 also having their second vaccination. The main risk to delivery is around vaccination supply; and • There are a range of initiatives in place to support increased uptake for some of the population groups where vaccine hesitancy is resulting in lower coverage. Kerry asked the committee to note Bradford Hospitals is still an outlier in terms of covid activity, the population Bradford Hospitals serve is central to Bradford and have a younger population that as yet in theory haven’t had their vaccination plus the challenges of the demographics of that population. As the vaccination programmes gets rolled out further down into the 18 – 40 group they should see the impact in terms of activity at the hospital. Robert asked if there was any indication of when the remaining number of CHC assessments will be cleared. Kerry confirmed as of 25th April there were 32 outstanding CHC assessments so may still be a challenge to clear before early May as planned. Neil highlighted in terms of the dashboards it does look as though there has been an improvement across the board, the only concern in the CCG was the 62 day wait for upgraded priority. Kerry confirmed in the CCG figures there will be other provider trusts so it could be some of the work that goes across to Leeds that is having the impact. Neil asked in terms of the number of patients over 52 weeks, this has gone up another 800 cases, but if you exclude the Airedale & Bradford numbers there are nearly 1300 additional over 52 weeks and presumably these are for Leeds. Kerry confirmed it could be any of the out of providers, there is activity at Calderdale but the majority will be Leeds. Chris confirmed there is a new contractual clause that they have put in place which providers have to provide weekly waiting list data, Bradford, Airedale and the acute trusts in West Yorkshire have signed up to this and are starting to submit. Kerry confirmed Trusts have put in plans to aim to recover to the levels they are been asked to around elective activity, whether that is achievable is a different matter but it does look like things are improving albeit Bradford is still predicting another surge end of May / June based on the modelling they have been doing. This is due to the different demographics of the centre of Bradford compared to the rest of the patch. Neil suggested there may be an expectation of some sort of bounce associated with the relaxation of restrictions. Kerry highlighted the covid dashboard has been reduced to weekly but will be stepped back up if things begin to escalate.
Recommendations; The Finance and Performance Committee: Noted the update. 6. Contracting Report Chris Balson gave an update. Key points to note: Bradford & Airedale Hospitals Trust Bradford and Airedale have been rolled forward into H1 and will see a similar pattern moving forward although the numbers may change.
Bradford District Care NHS Foundation Trust The Trust have confirmed that there will be a performance report (covering March 2021 data) at the next Board meeting on 13 May, following which they will report any exceptions within the F&P report in June.
Yorkshire Clinic – M12 Yorkshire Clinic at M12 have been operating under the original national IS framework contract.
401 402 Under the terms of this framework they are undertaking activity at the behest of the system, to help alleviate covid pressures. As such they are not fulfilling work under their existing contract and therefore are not reporting activity to us directly.
Currently, senior operational and management staff have maintained regular contact with the CCG to update on YC specific local system capacity with a particular emphasis regarding future planning and contractual arrangements.
There have been some issues getting patients out of Airedale hospital and into the Yorkshire Clinic, some of this is around consultant practising privileges and getting them up and running. The YC have confirmed they have 200 Consultants with practising privileges but only 5 theatres. Work is going well and the numbers are going through and if this continues the plan will be achieved at least from the independent sector point of view and will have to wait and see whether the hospitals will be able to achieve what their plans were.
As a system there will be a backlog of 11,500 patients split across the 3 organisations. The total acitvity the CCG has with the YC for the next 6 months is 6,000. This is the equivalent of using 12 months of the YC capacity working conistently to clear the backlog. Referals are continuing to come in. The YC are focusing on the ones that are prioritised which are the highest prioroity with the longest waiters.
Chris highlighted an operational problem where a couple of YC patients had cancelled their procedure within 24 hours of the appointment. The Covid safety protocols meant that these slots could not be reallocated. Robert asked how the YC were looking to manage that as if you continue to get significant levels higher than normal this will hit their bottom line and could there be a finanical risk in this arrangment. Chris confirmed this is not a risk for the CCG but is a risk for the YC and as a provider they are doing everything they can. Helen Farmer is working with comms to get a WY comms out to patients and the public highlighting this is a serious problem in the NHS and waste of resource. Robert highlighted if there are any financial issues that arise due to the scale of this, this will be picked up within the individual meetings.
YAS M12 The YAS position as reported at month 12. The month’s actual figures are reported to highlight the continued shift back to underperformance of Care Calls Answered. All CCG’s Total is shown to highlight the overall YAS activity position as at March 2021.
Enable 2 Slightly underspend this year and activity has been down.
Robert highlighted people are now working and accessing the services in a different way and what can be done to ensure they don’t go back to what they used to do which will have an additional cost of £2,000. Neil asked if the provider interpreter requirements were split off into the provider contracts and is this therefore just the Primary Care element. Robert confirmed it is and have only been looking at Primary Care for a couple of years. Kerry confirmed there has been a shift in the face to face verses virtual appointments and forecast a 6% increase in primary care appointments.
MEDEQUIP (AWC patients only) A report is currently being reviewed and will go to Robert re the possibility of moving this to a different provider or renew for next year.
Other Providers/ IS Framework Optegra YEH were included in the national contract through 20/21 and like YC were given notice that this would terminate at 24th December 2020 They rejected the offer of the new national contract and have negotiated a framework contract that covers the period 24th December to 31st March 2021.
402 403 Optegra extension agreed and signed which will take current agreement to 30th June 2021 Still working on the Westcliffe contract and not clear on the levels of activity they are able to achieve.
Bryan highlighted the focus of the contracting report now is about is getting patients treated in the optimal way and managing their resources correctly rather than who’s paying who for what and demonstrates they have changed their focus in the appropriate way in the contracting arena.
Bryan highlighted that even if the CCG use the maximum available independent sector facilities they will see an increase in the long waiters which is a concern. Chris confirmed they may see an increase in waiters and Bradford are making some progress with their over 40 weeks waiters and if the contracting team did the same report again in 6 months you would see an improvement in the over year waiters and 18 week waiters, but whether the overall number of waiters has increased that maybe the case. Bryan highlighted if the high priorities waiters and the long waiters reduced by the numbers going up that will be an indication of the work they are doing. Chris confirmed some of the national emphasis is around minimum waits and there are conversations ongoing saying the only way to deal with this long wait issue is that there are minimum waits that people should expect to wait, e.g. a minimum of 14 weeks before they are seen and then start to deal with the 52 week waiters and get them down and not expect to be seen in 4 weeks.
Neil highlighted in terms of the minimum waits this was an issue the CCG had previously had with the YC over the years, where they were able to process referrals in 0 – 10 weeks whilst in the local acute trusts it was nearer 18 weeks. Chris confirmed it is around the equity across the system and still have an imbalance and by setting minimum waits of 14 weeks you can start to expect that you will get a standard across everyone and setting maximum waits didn’t achieve setting a minimum wait and they might start to get there.
Robert highlighted in terms of the GB Helen is doing a planning requirement update and the finance plan will be presented as part of that section and the access report that will pick up the issues discussed in that report. Kerry confirmed there is also a performance update.
Recommendations; The Finance and Performance Committee: • Noted the update. 7. Finance Report Robert Maden gave an update. Key Points:
• The forecast position for costs within the fixed resource baseline shows operational budget underspends across commissioning and running cost budgets of £2.8m. This underspend is net of costs for which additional funding can be claimed and is unchanged from last month. Whilst the overall underspend has not changed, there has been a significant increase in mental health placement costs and additional continuing care activity. These costs have been offset by reductions in prescribing and primary care costs, and the release of surplus accrual balances.
• Reimbursement for Hospital Discharge Scheme costs and local acute independent sector activity costs has been confirmed and received for the six month period to March 2021 and is reflected in the reported position.
• Underspends against budgets for which additional funding can be claimed, i.e. the Hospital Discharge Scheme and local independent sector activity costs, are offset by a reduction in the value of the reclaim resulting in no impact on the CCG’s financial position.
403 404 • The baseline savings target of £1.2m has been covered by premises cost and support function savings, and a reduction in forecast prescribing costs.
• The position includes net COVID costs £3.19m against a budget of £2.91m with additional costs being incurred on Red Hub sites, PPE and staff overtime.
• After allowing for the increase in forecast mental health placement and continuing care costs, forecast budget underspends fully offset the additional savings target of £2.8m resulting in a break-even position for the six months to March 2021 and also for the 2020/21 financial year.
• On the basis of the forecast operational budget performance and subject to the audit of the Accounts, the CCG expects to meet its break-even financial target and its statutory financial targets for 2020/21.
Bryan highlighted in terms of the annual accounts and the end of the year the CCG will hit their targets. Bryan asked if the CCGs have affected next year’s plan by the way the 20/21 outturn has moved and what will be the potential scale of that change. Robert confirmed that actual outturn activity was c.£0.5m higher than the planning assumption, which is significant number in relation to the bottom line issue they are trying to resolve. To the extent that this is a recurrent pressure then this will be a first call on the contingency reserves, or other budget underspends should they arise. Neil highlighted there is overspend in Mental Health out of area and PCD and have those volumes been taken into account as you roll forward. Robert confirmed that this is part of the £0.5m assessment, but the recurrent impact will depend on the length of the out of area placements in particular. Neil asked about the risk of the £12M reimbursement figure not being fully realised, would this money be received. Robert confirmed that all of the related resource allocation adjustments had now been confirmed and no further changes are expected. Neil asked in terms of the 32 outstanding CHC assessment cases would this have an impact, Robert confirmed it will be a non-recurrent cost in 21/22 and will need to ensure that the assessments are completed as quickly as they possible.
Recommendations; The Finance and Performance Committee: • Noted the financial position for the six month period to the 31st March 2021 and the overall financial position for the 2020/21 financial year; and • Noted that subject to the audit of the Accounts for 2020/21, the CCG expects to meet its in-year breakeven target and its statutory financial targets. 8. System F&P Committee Minutes January & February The minutes of the System Finance & Performance Committee held on 21st January 2021 and 18th February 2021 were presented to the Finance & Performance Committee for information and assurance.
Bryan highlighted the membership for the System F&P is a wholly executive membership with a lot of officers but no Non Executives or Lay oversight and the need to think through where the independent challenge comes to the extent that decisions are delegated or made. Robert confirmed this extends across a number of ICP Committees or Boards and will be picked up through the ICP and ICS operating model development recognising that there is a gap.
Bryan highlighted looking at responsibilities for the transition work programme board, they will use members of Audit Committee to check on progress against transition and need to
404 405 use those decisions to ensure they are making decisions in the right way and confident they are properly tested and challenged to give some assurance.
Robert confirmed there will be a report that goes to the Executive Board presenting the position of e.g. finance, where you will see all the organisational level and Place performance. Also, recommendations would be made to this Board regarding performance and risk issues and also for decisions on the use of Place resources. Bryan & Neil highlighted they would both welcome this report.
ACTION: Session to be arranged to discuss the agenda going forward and feed back into the informal discussion formally through the transition board and look at where the real changes are being affected. Robert highlighted there are 3 meetings been arranged to map out what needs to go where and they are doing it from a what does the ICP need to see perspective and then what can be mirrored back. The results of this meeting to come back to the June F&P Committee to share the discussion about revamping future agendas.
Recommendations; The Finance and Performance Committee: • Received and noted the minutes of the System Finance & Performance Committee held on 21st January 2021 and 18th February 2021 9. Issues to highlight to SLT & GB • Performance generally is improving. 10. Any Other Business There were no items. 11. Date and Time of Next Meeting The next meeting will be held on Thursday 3rd June 2021 between 11am - 1pm via zoom
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Bradford District & Craven CCG Draft Minutes Quality Committee Meeting Thursday 1st April 2021 13:30-16:00 hours Zoom Call
Present:- David Richardson (DR) (Chair) Lay Member, Quality
Ruby Bhatti (RB) Lay Member Primary Care Commissioning Peter Brunskill (PB) Secondary Care Consultant Angie Clegg (AC) Independent Registered Nurse Bev Gallagher (BG) Head of Safety and Quality Improvement John Hartley (JH) Senior Head of Quality Improvement Fiona Jeffrey (FJ) Associate Director of Organisation Effectiveness Gill Paxton (GP) Associate Director of Quality & Nursing Helen Rushworth (HR) Manager – Healthwatch Dave Tatham (DT) Strategic Clinical Director of Keeping Well in Hospital Michelle Turner (MT) Strategic Director of Quality & Nursing John Young (JY) Secondary Care Consultant
Apologies:- No apologies were received.
In Attendance:- Bev Denton (Item 12) Corporate Governance Manager Sharonjit Kaur (Minutes) PA/Senior Officer
1. Introductions and Apologies: Apologies received as noted above.
2. Declarations of Interest: There were no declarations of interest.
3. Patient Experience: FJ talked to slides. It was reported that between the period 4th January-16th March, a total of 101 enquiries, concerns and complaints have been received. These included 38 MP and Counsellor enquiries. The common theme of enquiries and concerns were vaccination programmes, concerns related to funding issues for breast surgery, Tourette’s, Continuing Healthcare and waiting times for Autism Assessments. For primary care the issues were in relation to access, aspects of care, staff manner and attitude, requirements for reasonable adjustments and an issue pertaining to hearing and British Sign Language (BSL) which will be addressed with Bradford Talking Media.
Provider complaints received were in relation to clinical care, mental health and poor staff manner and attitude.
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The Engagement team have taken a lead on issues regarding Covid with the implementation of briefing Sessions. Volunteers and staff have assisted with the vaccine clinics. Support has been put in place for deaf individuals and work has been taking place to assist people of different communities with trialling of vaccination popup clinics.
Discussions will take place regarding Grassroots and other reporting mechanisms which have been paused for a year due to Covid. It was suggested that a Deep dive approach and a review of Grassroots would be supportive for the system. HR reported the launch of a survey to identify which social care topics individuals would like to be explored and to look at recurring themes. The responses will be used to prioritise engagement work and follow up on any significant concerns/share good news stories.
Action: FJ to report Grassroots progress at next meeting.
The Engagement team have been involved in the cervical cancer awareness week, working in collaboration with local, national and international newspapers and BBC.
National Planning guidance has been released and includes details of the recovery from the Covid Pandemic.
4. Minutes of the last meeting: Minutes of the last meeting were accepted as a true record in terms of content although have not yet been formerly signed off. Minutes will be circulated with any agreed amendments.
5. Action Log Update: The action log was updated at the meeting.
6. Matters Arising: There were no matters arising
7. CHC Audit: LM updated the committee on a CHC audit which was undertaken in 2019/2020. The purpose of the audit was to provide assurance around responsibilities for the CCG and LA in terms of CHC. A limited assurance rating was given. The overarching recommendations from the audit identified were:
Improvement in the governance framework Improvement in adherence to the CHC National Framework The need to improve monitoring and oversight including systems and data.
LM reported that 20 recommendations have been completed out of 24 and work is currently ongoing with the remaining 4. The Big ticket item for this audit is the implementation of a data platform which is fit for purpose for CCG and NHS England patient level dataset information which is required for April 2022. Demonstrations have taken place and an options appraisal will be the next step.
GP reported ongoing work in collaboration with Leeds to identify a system. Action: Progress to be discussed at QC in July 2021
It was reported that there are also 2 other audits currently being conducted which are:
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Section117 Mental Health aftercare audit which has gained significant assurance and Personal Health Budget which is ongoing.
8. Forward Planner: Deep Dive – what are the Committees top three questions for a deep dive? GP talked to slides outlining a potential new construction for quality committee. This would involve a “spot light on” session on alternate months, different ways for QC members to input into the meeting were discussed including the receipt of questions prior to the meeting to ensure a more definitive and focussed response on a specific issue. GP advised of the following areas which could be a starting point.
Research and Development; Mental Health; CHC, Complaints; PCD; and safeguarding. Alternate months regular reporting would be for information and the majority of the meeting focus on “spotlight on” a specific topic.
Other items of importance include the development of the ICS and staff wellbeing.
9. Quality Hub Slides: JHW talked to slides. JHW reported changes which will be made to the LeDeR Policy in line with ICS. There are several changes including the inclusion of Autism, and dedicated reviewers will be a requirement going forward.
Care at Home Workstream: BG updated the committee of ongoing work with the Care at Home Work stream. A reduction in Covid outbreaks has been reported across Bradford and Craven. Currently 18 care homes are within the 0-28 day cycle. Infections are mainly in staff groups. Any care homes where there are existing outbreaks will have additional scrutiny. The super rota has now been reduced to 6 hours per day Monday to Friday, 9 hours for Saturday and Sundays to enable continued support to Goldline.
All care homes have now been offered vaccines and early indications have suggested fewer deaths and admissions to hospital from care homes. It was also noted that new guidance has been released regarding visiting professionals to provide evidence of lateral flow testing. This information will be communicated to care homes in the near future.
Host commissioner responsibilities for people with LD and Autism in inpatient settings: A deadline date of 31st March 2021 was given for the implementation of host commissioner responsibilities for people with Learning Disabilities and Autism. Due to the impact of Covid and conflicting priorities this work has not been fully executed. However, a CCG Task and finish group is implementing interim oversight measures.
Safeguarding Adults: The committee were informed of a CQC inspection that took place at Cygnet Woodside and resulted in the unit being placed in special measures, an Organisational Safeguarding Enquiry (OSE) was held. Following the inspection in September 2020 an
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action plan was implemented. The unit has now exited the OSE process.
The company have made the decision to close the unit in May 2021 for refurbishment, and to reopen as a group of supported living flats. 4 clients are currently housed within the unit and weekly discharge meetings are taking place for a safe transition.
Cygnet Bierley has also entered an organisational Safeguarding enquiry (OSE) process as a result of issues similar to those of Cygnet Woodside.
Safeguarding Children: JH updated the committee of ongoing work with regards to Safeguarding Children. A weekly Task and Finish group is taking place to look at various areas including the Children Looked After (CLAS) action plan and a request has been made for additional health resources. MT has recently presented the ongoing work with the vulnerable children’s service to the Department for Education (DFE) at which health and senior leaders were present. Excellent feedback was received especially regarding progress made to date. Concerns were raised regarding sustainability of the progress and the need to embed the changes and improvements.
Covid Vaccine Update: 2nd vaccinations have now commenced across the District. Plans are also in place to review different ways for the community to access vaccinations. Provisions will be made for patients within the PCN 4 and PCN 6 catchment areas to receive vaccinations at mosques, where preferred.
Meds Optimisation: Discussions have taken place at SLT regarding patient safety concerns about the supply and monitoring of Warfarin. GP’s are able to prescribe Warfarin which is supported through BTHFT. TG and DT are continuing with work to explore the potential to roll the service out wider across the system.
PCD – CHC backlog issues JH reported that despite ongoing work the target for the CHC backlog has not been reached, due to members of the PCD team taking on additional duties for support in Covid Work. NHSE have required an action plan and new trajectory. Support is now in place from a staffing perspective and daily conversations to support pace and system unblocking are taking place. Completion of the work is now scheduled for the end of May 2021.
Quality Surveillance at ICS level
MT reported a presentation which was made to the Quality Surveillance Group regarding an emerging proposal for how partnership and engagement work could be developed. The information was also shared with H Hirst (Chief Officer, BD&C CCG), the ICS, Margaret Kitching (Director of Nursing) and Anthony Kealy (Locality Director, WYorks & Harrogate). The presentation outlined the need for collaboration between senior staff and providers.
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MT reported that strategic conversations are taking place to ensure the ICS developments are all inclusive and robust. DR asked for inclusion of lay members within the group.
10. Serious Incidents: JHW talked to slides Airedale – March 2021: 3 incidents were reported for March 2021, 1 of which is related to maternity issues and will also be reported to HSIB.
9 incidents are beyond deadline. JH reported the increase in incidents beyond deadline is as a result of Coroner’s inquests which were previously on hold have now resumed virtually via Webinars and a backlog of work has now commenced.
BDCFT – March 2021: 4 newly reported incidents which have been community suicides and 1 IG incident which involved CAMHS letters being sent to school and not sent to the school nurse.
There are currently 7 incidents beyond deadline due to coroner’s inquests capacity issues, Bradford District Care Trust have also worked with Rapid Reviews
BTHFT – March 2021: 1 incident has been reported. This was an issue of an agency domestic worker who was arrested. The investigation is currently suspended due to police and safeguarding involvement.
4 incidents have been reported beyond deadline.
YAS – March 2021: 2 incidents have been reported. 1 incident related to an ambulance crew arriving at the incorrect address and 1 incident from Leeds.
JH informed the committee of an increase in the number of incidents reported from Leeds.
MT requested for the patient safety strategy to be discussed and share learning across the system.
11. BDCFT CQC Update: Slides were presented by JHW regarding CQC reports and inspections. It was noted that an inspection was carried out at BDCFT during 2019 which was reported to have an inadequate rating. A further inspection carried out in 2020 showed improvements had been made and focus was put onto acute wards and the Psychiatric Intensive Unit. Following the 2020 inspection, another inspection took place in 2021 although as this was an interim inspection a rating was not given. Overall feedback was positive.
The key findings were that there were 8 “should do” actions which showed a decrease from 10 the previous year.
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In order to provide further support JHW and KV are attending monthly patient and safety learning forums which include learning and sharing from risks and SI’s.
It was acknowledged that although progress has been made, work is still ongoing for further improvements.
Key messages of good practice from the inspections were:
Services are good Wards are safe and clean Adequate clinical staffing levels Medication storage is safe Good practices regarding Safeguarding issues Use of Mental Health Act and Mental Capacity Act has improved Compassion and kindness from staff to patients is good Areas are well led
The following issues were raised regarding Fern Ward:
Daily environmental reviews were not carried out Managers office which is too close to the clinic room Mandatory training numbers were low especially practices such as Basic Life Support, Control and Restraint – it was however acknowledged that numbers being low are impacted by the current pandemic Inconsistencies with Personalised Care Plans and Discharge Planning Advocacy services not shared with patients Clinical Supervision inconsistent
Progress regarding the above was acknowledged and a further unannounced visit will take place although timescales have not yet been given.
SystmOne
The committee were briefed by MT on a SystmOne issue which has been raised by JT. Concerns have been raised regarding IT connectivity and speed of systems at Crosshills and Fisher Medical Practice. Work has commenced to discuss the issues with the involvement of system partners including HH. A table top exercise has been carried out with Modality and IT to identify any patient safety incidents. No patient safety incidents have been highlighted, although the speed of sending documents and results has been slow which has resulted in concern for patient’s safety. A meeting has taken place this month with a further review to take place at the end of April 2021. Windows 10 will be implemented in May 2021 which will assist with the improvement in speed of connectivity.
12. Risk Register: BD (Corporate Governance Manager) informed the committee of discussions which have commenced regarding the management of risks into Business As Usual in relation to the transition to ICS/ICP.
The following update was given regarding the Risk Register as of 26 March 2021.
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There are a total of 48 open risks on the CCG risk register. At committee level, the number and average score of open risks are currently as follows: 25 are aligned to Quality Committee 20 aligned to Finance Performance Committee and 3 to both Finance Performance Committee and Quality Committee.
Of the 25 QC risks, 4 are classed as critical, 9 are serious with a further two serious risks aligned to both Quality Committee and Finance Performance Committee.
The following 3 new risks have been added to the register:
Staff burnout which is rated as 15, SystmOne functionality issues which is a Finance and Quality risk which is again rated as 15 and a risk in relation to delayed access to elective care - rated as 12. 2 risks have decreased in score – unidentified unpaid carers and engagement with people and communities. 1 risk has increased from 9 to 16 – impact of CHC referrals.
1 risk is marked for closure which is the population being negatively impacted due to lack of prioritisation for services which has been superseded by the delayed access risk.
It was also noted that the Covid Risk Register and Corporate Risk Register are now aligned as one Risk Register.
13. Items for Escalation to Governing Body/System Quality Committee: The committee requested that the positive improvements regarding the impact of the Children Looked After work led by MT (Strategic Director of Nursing and Quality) to be escalated to the next Governing Body.
14. Any Other Business: Performance Report – The Performance report was circulated for information As a result of a visit from BTHFT to the Mediscan facility, both BTHFT and the CCG have suspended referrals to Mediscan until such time as the concerns raised have been addressed. GP’s and patients are aware, and patients have been redirected to the Yorkshire Clinic. BTHFT have offered support to Mediscan to address the improvements. Changes have been requested to the delivery of the Neonatal BCG Vaccination by Public Health England. The changes made will be for babies to be vaccinated at 4 weeks which is a move from immediate post-natal vaccination. There was discussion around the need to ascertain and understand risks alongside responsibilities of who will administer the vaccination.
15. Date and Time of Next Meeting: Thursday 6th May 2021 at 1.30pm via Zoom
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Bradford District & Craven CCG Draft Minutes Quality Committee Meeting Thursday 6th May 2021 13:30-16:00 hours Zoom Call
Present:- David Richardson (DR) (Chair) Lay Member, Quality Angie Clegg (AC) Independent Registered Nurse James Thomas (JT) Clinical Chair Bev Gallagher (BG) Head of Safety and Quality Improvement John Hartley (JH) Senior Head of Quality Improvement Kate Varley (KV) Senior Head of Patient Safety Jackie Haw-Wells (JH) Head of Patient Safety & Quality Improvement Fiona Jeffrey (FJ) Associate Director of Organisation Effectiveness Dave Tatham (DT) Strategic Clinical Director of Keeping Well in Hospital Michelle Turner (MT) Strategic Director of Quality & Nursing John Young (JY) Secondary Care Consultant Peter Brunskill (PB) Secondary Care Consultant
Apologies:- Ruby Bhatti (RB) Lay Member Primary Care Commissioning Gill Paxton (GP) Associate Director of Quality & Nursing Helen Rushworth (HR) Manager – Healthwatch Nadine Cullimore (NC) Senior Head of Personalised Commissioning
In Attendance:- Jude MacDonald (Item 8) Designated Nurse Safeguarding and Children Looked After Dawn Clissett (Item 9) Snr Head of Strategy, Change and Delivery Lauren Ward Safety & Quality Improvement Senior Manager Elaine Phelps (Minutes) PA/Senior Officer
1. Introductions and Apologies: Apologies received as noted above.
2. Declarations of Interest: There were no declarations of interest.
3. Minutes of the last meeting: Minutes of the last meeting were accepted as a true record of the meeting.
4. Action Log Update: The action log was updated at the meeting.
5. Matters Arising: There were no matters arising
6. Forward Planner: KV told the meeting that the Quality Hub have contributed and put forward items to be brought to QC for assurance purposes for comment and discussion by the meeting and for feedback. There is room within the planner for adding any issues outside of those we can predict. The focus has been on statutory functions with contemporaneous updates as required with a link into the ICS.
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MT said this has been undertaken to make sure we have learnt from the last year going through Covid and the findings of an internal audit to make sure we have discharged our statutory duties in timely manner and to ensure that as we move to SQC arrangements how do we close down CCG QC in a way that is responsible and in line with the terms of reference
MT/JT are working closely to align across Place/organisation.
The meeting accepted the forward planner and that it reflects the conversation and a connection with the SQC forward planner
7. Quality Slides: JH talked through the slides that had been circulated prior to the meeting. SQC: The update on SQC is for information on work being to gain assurance that the correct discussions are taking place and in a structured way.
Vulnerable children: A new clinical model has been implemented and the team are looking to have the backlog cleared by September 2021 and a GPSi has been requited to help with this.
CYP Mental Health: The dashboard has been agreed jointly with the local authority and performance data is being shared.
Review of Complex Children: The CCG is looking at moving to the Doncaster model and this will be discussed at a meeting on 19th May 2021.
0-19 health Services: There is an interim wrap around model in place to support school nursing and a more sustainable model is to be discussed with CCG and BMDC responsible officers. An audit of health visiting input into safeguarding is to be completed by May 2021
SEND: The team are working to a number of deadlines including the impact of QA framework and audit tool to be reviewed in Q3 2021. The ownership of outstanding risks is to be clarified with BMDC at SEND Partnership
Key quality outcomes: The 18 week performance continues to be a challenge as, although outpatient activity continues, elective capacity has been significantly impacted by Covid-19. As a result 52+ weeks breaches are increasing and there are 19 patients at BTHFT who have waited over 104 weeks. Strategic discussions re restart and recovery have been planned from the end April 2021. Diagnostic performance continues to improve and Cancer services continue to be maintained with a reduction in those who have waited over 62 days. Increased referral rates are putting pressure on mental health services including CAMHS The delivery of LD annual health checks is currently forecast to be above our recovery plan at 72% for 202/21. BTHFT saw A&E attendances increase in line with pre Covid-19 levels whist ANHSFT saw attendances decrease slightly during February 2021.
LeDeR: There are currently 95 reviews reported in phase 2 for West Yorkshire, 17 have exceptions, 49 have been completed (62% of those which have no exception) and 29 still in progress. For BD&C CCG there have been 21 cases reported in Phase 2. 11 reviews are ongoing. 20 have been completed since 1st January 2021. In preparation for new software no new reviews could be allocated after 28th February. These are expected to be released from 1st June 2021 on the new system as Phase 3. Nationally each ICS needs to nominate an SRO for LeDeR by June 2021. The WY ICS hosted serviced gained permission from NHSE/I to put a model in place that builds on current arrangements and is in line with the WY ICS and Placed based thinking.
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Care at Home/Ageing Well - A scoping exercise is in progress to understand how the Enhanced Care in Care Homes, Directed Enhanced Service specification is being delivered across PCNs, Community services and care Homes. Outcomes will be shared with all PCNs and the Ageing Well Board to share best practice and understand any system risks/gaps to implementation. A new end of life Clinical lead has been successfully appointed and will be focusing on Advance Care Planning, SystmOne templates and Marie Curie Daffodil standards.
JY asked is the move to the Marie Curie Daffodil standard instead of the Gold Standard Work. ‘Daffodil standards complement existing EOL care with a series of quality statements reflective learning exercises and quality improvement activities’. BG said she was not aware of this replacing the Gold standards framework and JT stated that the Royal College of GPs is pushing/supporting this. Action: JT to get further information.
Designated Covid-19 beds in NYCC and Bradford are no longer being used as Covid-19 designated beds and will return to standard nursing home beds.
There are currently 6 care homes rated as outstanding and 91 rated as good. There has been a further increase in homes that require improvement and 7 care homes placed in special measures due to an inadequate rating. In domiciliary Care currently 1 provider is rated as outstanding and 61 providers have been rated as good. 9 providers have been rated as requires improvement and there are no providers with an inadequate rating.
Host Commissioner Responsibilities for people with LDA in inpatient settings: Discussions with BDCFT and ICS are ongoing, however due to the impact of Covid-19 changes in roles and responsibilities and conflicting priorities have meant that a permanent solution has not progressed in time for the 31st March 2021 implementation. Interim arrangements at a CCG level have been implemented to ensure that our statutory duties are discharged from 1st April 2021 whist we continue to work through the options. It is envisaged that these interim arrangements could be transferred to Place and/or ICS once the model is established to ensure continuity and consistency of oversight arrangements is maintained.
Primary Care - Quality Assurance: The CCG continues to support the temporary suspension of the Contract and Quality Assurance process until April 2021. As inspections remained suspended until April 2021 there have been no changes to practice ratings. Bradford District & Craven currently have 67 practices CQC rated as ‘Good’, 3 ‘Outstanding’ and 2 ‘Requires Improvement’. Inspections resumed from April 2021.
It has been agreed that the Hillside Bridge Red Hub is to close with contingencies in place in case it needs to reopen.
Safeguarding Adults: A draft of the regional safeguarding assurance standards was circulated to provider safeguarding leads for consultation with a closing date of 20th April, 2021. There are a number of statutory reviews that are being undertaken/due to commence including Domestic Homicide Reviews and Safeguarding Adult Reviews all of which are resource intensive.
Safeguarding Children: The SQC Task and Finish group continues to focus on Designated Dr Children in Care, School Nurse Child Protection Pathway, CQC Children looked after Action
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Plan, SEND, Children and YP MH. There are anticipated capacity issues within the team due to the Deputy Designated Nurse leaving with the possibility of increasing current hours of job share deputies.
R&D: The 15th version of the LAMP report has been produced and is informing the response across the region and continues to form part of the AMR response across the region. The Novavax vaccine trial and the AstraZeneca monoclonal antibody trials continue and the team are currently planning to restart a number of projects that were all paused at the start of the pandemic.
Medicines Optimisation: The PCN sites continue to run well and the Jacobs Well site is supported by members of the Meds Opt team. Windhill & Saltaire, 5 Lane Ends and Bingley Bubble PCNs are to withdraw from the under 50’s cohort (they will still complete the second doses for cohorts 1-9). Currently there are low vaccine supplies for first doses but second doses are still going ahead.
Following concerns from JY re the withdrawal of GPs from the vaccination programme, JT told the meeting the GPs were initially contracted to do cohorts 1-9 and the option has now come up for GPs to pull out particularly with the increase in community sites and the national booking system. Those coming out are mainly due to practical reasons, in terms of staffing, keeping things going within the practice. There is also an issue around the ability to store the Pfizer vaccine.
Further discussions are required re prescribing issues with Psychiatry UK. This is an issue around Neuro diversity (previously known as Autism) that has been contracted out to Independent providers to clear waiting lists but we have not worked through the medication requirements. Psychiatry UK advice is at odds with what is commissioned locally.
Personalised Commissioning: There are currently 26 cases remaining on the CCG backlog and the team are on track to clear this within the current timescales. All new referrals are receiving care packages, needs are being met and the team are ensuring that no serious clinical risks are being missed.
The Section 117 audit is marked as significant assurance near completion and the Joint CHC Audit and PHB audit are shown as near completion.
The Section 117 audit significant assurance relates to the creation of a framework but does not give significant assurance in terms of the implementation of that framework which is an important part of the assurance this committee needs and will come in the fullness of time. In terms of Personal Health Budgets there are a number of recommendations with remaining actions.
SEND: This slide highlighted what is working well and what we need to improve. Working well: Health & Partnership working, intelligence and Data, Co-Production and Voice, CYP Learning Disability/Neuro-Diversity, CYPMH Act as one transformation programme, RIC What we need to Improve: Quality of Health’s contribution to EHCP’s, Neuro Diversity, Learning Disability, Response to Trauma, 0-19 Services, Data and Intelligence.
8. CLAS Review: Jude Macdonald attended to talk about the review of the CLAS Action plan following the CQC inspection in 2019. This action plan is now out of date given the time since the review, the
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Covid-19 pandemic restrictions and shift in priorities for the health system due to this. It is felt that we need to focus on assurance and to be ‘visit ready’ should another review be undertaken and to consider where we are now and what needs to happen with any identified risks. Conversations have been held across the system and providers have agreed to go back to the original action plan and provide apposition statement for green actions, i.e. are they still fully actioned. The team want to capture positive steps taken to undertake these actions during Covid. The new plan will be presented to QC and SQC for review once complete.
9. Staff Wellbeing Fiona Jeffrey and Dawn Clissett guided the meeting through the slides previously circulated. Wellbeing services are part of our contract with BDCFT and have been significantly developed over the last 12 months. There has been a mixture of formal, semi-formal and formal interventions from formal risk assessments to informal wellbeing zoom sessions.
NHS Staff Survey There were two questions in the staff survey about health and wellbeing, the first was ‘the organisation definitely takes positive action on health and wellbeing’ this scored 54% an increase of 11% from last year and 7% higher than the Picker average but SLT did find this score disappointing. The second question ‘My immediate manager takes a positive interest in my health and wellbeing’ scored 88% again an increase of 5% from last year and 7% higher than the Picker average.
Staff Wellbeing Group This was set up with representation from across the CCG including staff networks and parallel strands of work were identified. Supporting staff wellbeing - raising awareness of and strengthening our current offer System transformation and transition - supporting staff through changes and addressing uncertainties that come with reorganisations
Staff Wellbeing There is a wide range of things on offer to staff including: Regular wellbeing bulleting Monthly wellbeing zooms and individual calls Fund days Mindfulness Workouts Posture and physio Act as One festival
Wellbeing Guardians Two board level wellbeing guardians have been appointed in line with the NHS People Plan commitment to create a working environment where we are compassionate and inclusive, safe and healthy and have a voice that counts’. These are John Young and Angie Clegg. Their role is to provide assurance that the CCG is a wellbeing organisation and a healthy workplace in which NHS staff and learners can work and thrive and be a critical friend ensuring a compassionate leadership style.
Wellbeing principles - draft Some draft principles have been put together in conjunction with the Staff Wellbeing Task and Finish Group.
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Staff engagement Session (27th April) There was a lot of positive feedback about the range of support on offer; however there was a challenge around time to access wellbeing support.
BD&C Workforce wellbeing This began in week 1 of lockdown in March 2020. Informal weekly calls brought together a mixed group of professionals able to understand emerging need and level up offs for all health and care staff across Bradford District & Craven. These were shared through organisations’ own routes and West Yorkshire & Harrogate Partnership website hosted a shared wellbeing page. The group continues to meet and is now formalising progressing work streams within the looking after our people programme of Bradford District & Craven integrated people plan. In parallel, a ‘single front door’ is being opened via Bradford District & Craven ‘one workforce’ website, designed to share resources, facilities and promote events coming up. The chair commented that this is a great example of what a caring organisation we are.
10. Update on Grass Roots Since the last meeting discussions have taken place regarding Grass Roots. There has been a pause on the bi monthly reports that came to QC, those reports identified all the themes across all the services, however the work still continued on targeted pieces of work. There have been challenges in looking at restarting and FJ/GP are to take this to SQC to explore how to take this forward and get the high level buy in across the system and try to unblock some of the challenges the team have experienced. We are paying our licence fee for the Memberships Engagement Services until the end of March 2022 so we still have time to decide what to do as a system.
11. Serious Incidents ANHST have reported one new serious incident. There are seven beyond deadline one of which is under stop the clock, a number are due to Coroners inquests being delayed
BDCFT have reported two new incidents. There are two stop the clock beyond deadline and five others overdue with managed extensions.
BTHFT have reported three new incidents. Two of these are part of the new NHSE national guidance. There are three over deadline.
YAS have zero incidents to report this month and have one overdue.
Independents Yorkshire Clinic - have 2 incidents reported, they are different incidents but are the same type of incident. There is currently an incident overdue from Sheffield.
The SQC plans to receive the outcomes and learning from a deep dive on SIs involving people with acute mental health problems involving BDCFT, ANHSFT, BTHFT and the CCG teams.
KV reported that we have had three incidents at the neonatology unit at BRI. The team received immediate verbal updates from the Chief Nurse at BRI as soon as these incidents were identified. BTHFT had already decided to commission an independent review of the
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incidents. MT will discuss directly with Karen Dawber about who is commissioned to complete that review. An update will be brought to the next meeting.
12. Items for escalation to Governing Body/System Quality Committee Wellbeing work Assurance re issues dealt with at SQC
13. Any Other Business: Performance Report – The Performance report was circulated for information
Date and Time of Next Meeting: Thursday 3rd June 2021 at 1.30pm via Zoom
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Bradford District & Craven CCG Minutes Quality Committee Meeting Thursday 3rd June 2021 13:30-16:00 hours Zoom Call
Present:- David Richardson (DR) (Chair) Lay Member, Quality Angie Clegg (AC) Independent Registered Nurse James Thomas (JT) Clinical Chair Bev Gallagher (BG) Head of Safety and Quality Improvement John Hartley (JH) Senior Head of Quality Improvement Jackie Haw-Wells (JH) Head of Patient Safety & Quality Improvement Fiona Jeffrey (FJ) Associate Director of Organisation Effectiveness Dave Tatham (DT) Strategic Clinical Director of Keeping Well in Hospital John Young (JY) Secondary Care Consultant Gill Paxton (GP) Associate Director of Quality & Nursing Helen Rushworth (HR) Manager – Healthwatch Ruby Bhatti (RB) Lay Member Primary Care Commissioning
Apologies:- Kate Varley (KV) Senior Head of Patient Safety Michelle Turner (MT) Strategic Director of Quality & Nursing Peter Brunskill (PB) Secondary Care Consultant
In Attendance:- Helen Ruck Safety & Quality Improvement Senior Manager Jacqui McMahon Safety & Quality Improvement Senior Manager Bev Denton (Item 9) Corporate Governance Manager Elaine Phelps (Minutes) PA/Senior Officer
1. Introductions and Apologies: Apologies received as noted above.
2. Declarations of Interest: There were no declarations of interest.
3. Minutes of the last meeting: Minutes of the last meeting were accepted as a true record of the meeting.
4. Action Log Update: The action log was updated at the meeting.
5. Matters Arising: There were no matters arising
6. Quality Hub Slides JH talked through the slides that were circulated prior to the meeting
LeDeR: National guidance has been published and each ICS needs to nominate and SRO for LeDeR by June 2021. New NHS commissioned software is to be launched to enable phase 3 reviews to be released from June 1st, 2021.
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95 reviews were reported in phase 2, 17 have exceptions, 49 have been completed and 29 are still in progress for West Yorkshire. Bradford reported 21 cases in phase 2 of which 20 have been completed. Bradford are also reviewing a further 10 cases for other CCGs as part of the West Yorkshire Hosting
Care Sector: Infection rates have reduces with 2 homes in Bradford reporting an outbreak within the 0-28 day cycle. There are no outbreaks reported in Craven. The Covid-19 support team are switching to recovery focus.
Care at Home/Ageing Well: A review across the PCNs is in progress to establish the current state of implementation of Enhanced Health in care home specifications against the GP directed enhanced Service (DES). The System have agreed to continue to fund Telemedicine in care homes until September 2021 whilst a review of the most cost effective future digital support offer for care homes take place.
Host Commissioner: The CCG currently commission placements for 6 people and individual 6/8 weekly visits are completed by PCD. Currently there are 16 placements for Learning Disabilities and Autism within the 4 MH hospitals and 1 LD hospital and discussions are taking place re the long term objective for a service design enabling WY ICS oversight and for BDCFT to take on medium term responsibilities for Host Commissioner are ongoing.. Short term interim arrangements are being undertaken by the CCG NHSE have confirmed they will be corresponding with Cygnet Hospitals re the lack of serious incident reporting as part of QRM actions. Cygnet Woodside is to close on 28th May, 2021
Safeguarding Adults: Liberty Protection Safeguards will be launched in April 2022 and the potential for a joint health team at Place is being explored. An increase in statutory reviews is impacting on team capacity along with a 1WTE vacancy.
Safeguarding Children: Scoping of additional health requirements for the integrated front door/child exploitation hub is underway and a Designated Dr options paper has been submitted to SQC. A new clinical model for Children in care has been recruited to and is now live. Again an increase in complex cases and statutory reviews is impacting on staff together with a 1WTE vacancy
Children’s Services: The SEND inspection is anticipated in June 2021 and weekly system preparatory meetings are underway and clinical leads are now in place. Six apprentices are completing their first year and eight more are to be recruited for next year.
CAMHs: there has been an improvement in the waiting list although the complexity of children’s mental health needs continues to impact on referral to assessment.
Autism (Children & Adults) the waiting lists continue to be very challenging and transformation funding plan proposal is in draft format and awaiting sign off
Research & Development: A place based research website and registry has been launched on international clinical trials day 20th May, 2021. The campaign to reduce opioid prescribing (CROP) is now also operational in the North East and South Yorkshire. A qualitative review of CROP is to be published in the British Journal for General Practice.
Primary Care: The Red Hub at Hillside Bridge health Centre will close on 28th May 2021. A step down plan has been produced which also includes a step up plan if necessary. Three PCNs have withdrawn from vaccination cohorts 10-12. Under 40’s are no longer to be offered Astra Zeneca Vaccine for first doses following national guidance. Due to the increase in the Indian variant second doses for cohorts -19 are to be brought forward from 11 to 8 weeks.
Medicines Optimisation: The regional pharmacist is providing supportive leadership to the Area Prescribing committee (APC). QIPP planning for 21-22 is underway to ensure the alignment of system priorities. And a framework for collaborative working between West
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Yorkshire and Harrogate Health and Care Partnership and the pharmaceutical industry is underway. A paper was submitted to SLT on 26th May re Psychiatry UK prescribing issues.
Personalised Commissioning: All cases have been completed within the CHC Covid-19 backlog and the new referral caseload has a waiting list of 58. All new referrals are in receipt of care packages. A process is being developed for Children’s continuing care to ensure that the child is at the centre of the decision making process and that funding is secondary. The PHB audit is near completion and the Children’s audit is awaited
7. Serious Incidents ANHSFT have reported 0 new incidents in May. There are 7 beyond deadline and one ‘stop the clock’.
BDCFT have reported 4 new incidents and have 7 beyond deadline.
BTHFT have reported 2 new incidents and have 4 beyond deadline
YAS have reported 0 incidents in May and have 1 beyond deadline
Independent Providers Yorkshire Clinic have reported 3 new incidents all for surgical/invasive procedure incidents
The LeDeR annual review is due at the end of June and this along with the quarterly SI report will circulated prior to the next meeting.
8. On the Horizon: There have been a number of complaints/concerns throughout April and May covering the CCG, Primary Care, providers and MH services. A number concerns have also been raised re Covid vaccines including not heard/invited for an appointment, the timeframe/wait for second dose, the location of sites, supply issues and the difficulty in booking via the National Booking System. A covid vaccine update is to be given at the next meeting. Grassroots: the team are continuing to work with partners to expand sources of feedback and is now being received from a number of sources The comms team are supporting message regarding vaccine uptake along with coordinating messages to address demands in ED to ensure positive messaging around general practice. The staff networks have all been involved in updating key HR policies and presented at SLT meetings
9. Risk Register Work is continuing to encourage risk owners and senior managers to review risk scores and narratives to ensure the risks are updated in line with recommendations made by Internal Audit. There are 49 open risks on the corporate risk register of these three ‘critical’ level risks align to the Quality Committee along with seven ‘serious’ level risks. One new risk has been aligned to the Quality Committee (Risk 1861 BCG Vaccine delivery) and two have been aligned to both Quality Committee and Finance and Performance Committee. (Risk 1858 re the dis-establishment of the CCG and Risk 1857 Staff wellbeing) Seven risks aligned to the Quality Committee have decreased in score this cycle, no risks have increased and one risk has been marked for closure. This relates to Local Care Direct capacity.
10. Items for escalation to Governing Body/System Quality Committee There were no items for escalation
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11. Any Other Business: Performance Report – The Performance report was circulated for information
Date and Time of Next Meeting: Thursday 1st July 2021 at 1.30pm via Zoom
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