Governing Body Meeting of Lincolnshire East Clinical Commissioning Group (CCG)

Held in Public on Thursday, 23 January 2020 at 1.30 pm

Venue:

The Golf Hotel The Broadway Woodhall Spa Lincs LN10 6SG

For further information please contact:

Claire Wilson Corporate/Board Secretary Email: [email protected] Tel: 01522 515347

GOVERNING BODY MEETING HELD IN PUBLIC

Lincolnshire East Clinical Commissioning Group (CCG) will meet on Thursday, 23 January 2020 at 1.30 pm at The Golf Hotel, The Broadway, Woodhall Spa, Lincs, LN10 6SG A G E N D A

Time Standing Items Paper Presenter 1.30 pm 1. Welcome & Introductions Verbal Dr Doddrell

2. To receive apologies for absence:- Verbal Dr Doddrell  Mr John Turner  Mrs Brenda Owen

3. To receive any declarations of pecuniary and non- Verbal Dr Doddrell pecuniary interests  Members are reminded of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of Lincolnshire East CCG.  Declarations declared by members of the Governing Body are listed in the CCG’s Register of Interests. The Register is available within these papers, in addition to also being available via the Corporate/Board Secretary or on the CCG’s website at the following link: http://www.lincolnshireeastccg.nhs.uk/

1.30 pm 4. To approve the minutes of the meeting held on 28 November Enclosure Dr Doddrell 2019 5. To consider any matters arising from the previous minutes Enclosure Dr Doddrell and review the Action Log

Time Items Recommended for Decision/Approval/Ratification Paper Presenter 1.45 pm 6. (a) To approve the extension of review dates for all Policies Verbal Mrs Ball for Lincolnshire East CCG until the 31 March 2020

(b) To approve the co-opting of an additional Lay Member for Verbal Mrs Latham- the Audit Committee Green

Time Items for Discussion/Comment Paper Presenter 1.55 pm 7. (a) To receive an Update from the CCG Chair & Chief Verbal Dr Doddrell/ Operating Officer Mrs Williamson a. Update on the new Lincolnshire CCG Enclosure

2.10 pm (b) To receive the Update Report from Healthwatch Enclosure Mrs Moulder

2.25 pm (c) To receive a Quality report on United Lincolnshire Enclosure Mrs Ball Hospitals Trust (ULHT) 2.40 pm (d) To receive a Quality report on Northern Lincolnshire & Enclosure Mrs Ball Goole (NLAG) NHS Foundation Trust

2.50 pm (e) To receive the Learning Disability Mortality reviews Enclosure Mrs Ball (LeDeR) Annual Report 3.00 pm (f) To receive the Integrated Performance Report Enclosure Mrs Williamson

3.15 pm (g) To receive the Financial Monitoring Report Enclosure Mrs Williamson

3.30 pm (h) To receive an update on Cyber Security Enclosure Mrs Ball

3.45 pm (i) To receive a report on EPRR Core Standards Enclosure Mrs Williamson

3.55 pm (j) To receive an update on Public Health issues Verbal Mr McGinty

Time Items for Noting, Reference and Information 4.05 pm 8. (a) To receive the Exception Report from the Countywide Enclosure Dr Boldy Quality & Patient Experience Committee (QPEC) held on 19 December 2019 (b) To receive the Exception Report from the Primary Care Enclosure Mrs Owen Commissioning Committee meeting held on 7 November 2019 (c) To receive the Escalation Report from the Audit & Risk Enclosure Mrs Latham- Committee held on 16 December 2019 Green (d) To receive the minutes of the Health Scrutiny Committee Enclosure Mrs Ball held on 16 October 2019 (e) To note the MP Correspondence Log Enclosure Mrs Ball

(f) To note the Freedom of Information Log Enclosure Mrs Ball

(g) To note the Caldicott Monitoring Log Enclosure Mrs Ball

Time Closing Items 4.10 pm 9. To consider any potential risks identified during the meeting Verbal Dr Doddrell

10. To receive any questions from the public relating to items on All Dr Doddrell the Governing Body agenda

4.15 pm - CLOSE OF MEETING Date of Next Meeting: Thursday, 26 March 2020 at 1.30 pm – Public Governing Body Meeting The Len Medlock Centre, St George's Road, Boston, PE21 8YB

Please forward any apologies to [email protected] 01522 515347

Please note that all of the Agenda times are approximate and subject to change

The items on this agenda are submitted to the Governing Body for discussion, amendment and approval as appropriate. They should not be regarded, or published, as organisation policy until formally agreed at a Governing Body meeting at which the press and public are entitled to attend. Papers are available on the NHS Lincolnshire East CCG website: www.lincolnshireeastccg.nhs.uk

In case of difficulty accessing the papers, please contact Claire Wilson Corporate/Board Secretary on 01522 515305 or via e-mail at [email protected]

As part of the Clinical Commissioning Group’s commitment to openness and accountability, meetings of the Governing Body are held in public and members of the public are invited to attend. Anyone may ask a question relating to items on the agenda in advance of each meeting. Such questions will be responded to at the meeting.

Please submit your question to Claire Wilson - deadline for submission of questions Tuesday, 21 January 2020

The Governing Body will be asked to consider the following resolution: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest’

(Section 1(2) Public Bodies (Admission to Meetings) Act 1960) Items in the private part of the meeting are either commercial in confidence or relate to individual staff and patients.

…………………….………………………… Claire Wilson, Corporate/Board Secretary

Members:

Dr Andrew Doddrell Clinical Leader, Boston Locality/CCG Chair Mr John Turner Accountable Officer, Lincolnshire CCGs Mrs Sandra Williamson Chief Finance Officer/Interim Chief Operating Officer

Mrs Liz Ball Chief Nurse Dr Neal Parkes Clinical Leader, East Lindsey Locality/Deputy Clinical Chair Dr Seng Keat Ko Clinical Leader, East Lindsey Locality Dr Stephen Savory Clinical Leader, Skegness & Coast Locality Mrs Tracey Latham-Green Lay Member – Governance Mrs Brenda Owen Lay Member – Patient & Public Involvement Dr Brynnen Massey Lay Member – Primary Care Dr David Boldy Secondary Care Doctor

Attendees: Mrs Lyndy Moulder Healthwatch Representative Mr Tony McGinty Consultant in Public Health Mrs Claire Wilson Corporate/Board Secretary

RECOMMENDATIONS TO THE GOVERNING BODY GLOSSARY OF TERMS

To approve An item of business that requires the Governing Body to make a formal decision

To endorse An item of business that requires the Governing Body to endorse the actions taken by the NHS Lincolnshire East CCG to a multi- organisational decision

To ratify An item of business where the Board is required to ratify the actions taken on behalf of NHS Lincolnshire East CCG, e.g. decisions taken by a Governing Body Committee

To consider/receive A report containing a positional statement relating to the delivery of NHS Lincolnshire East CCG’s functions for which the Governing Body has a corporate responsibility but is not explicitly required to make a decision

In some circumstances there may be a requirement for the Governing Body to adopt the measures contained within the report

To discuss An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the CCG’s Officers

For information (to An item of business that is of general interest but is not of significance to receive/note) the Governing Body’s corporate or operational activities. These items will be included on the agenda but will not be for significant discussion or require a decision

All these terms apply to the Governing Body and its Committees and Sub-Committees.

All members of NHS Lincolnshire East CCG Governing Body understand and are committed to the practice of good governance and to the legal and regulatory frameworks in which they operate.

All members of NHS Lincolnshire East CCG Governing Body abide by the Standards for Members for NHS Boards and Clinical Commissioning Group Governing Bodies in England. http://www.professionalstandards.org.uk/docs/default-source/publications/standards/standards-for-members-of-nhs- boards-and-ccgs-2013.pdf?sfvrsn=2

Declarations of Interest - Definitions

In line with guidance, the definitions of conflicts of interest as referred to in the CCG’s Policy on Standards of Business Conduct are circulated with the agenda for the meeting.

All those attending the meeting should carefully consider whether they have any actual, potential or perceived conflicts of interest in relation to the items of business on the agenda and if so give notice to the Chair and/or Corporate/Board Secretary prior to the meeting.

An extract from the CCG’s Register of Interests is enclosed in the papers and the Chair will confirm at the meeting whether anyone has any actual, potential or perceived conflicts in relation to agenda items under discussion.

A ‘conflict of interest’ is defined as:

“A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”

Interests can be captured in four different categories:-

Type of Interest Description

Financial This is where an individual may get direct financial benefits from the consequences of a Interests 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 health or social care organisations. This includes involvement with a potential provider of a new care model;  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 health or social care organisations;  A management consultant for a provider; or  A provider of clinical private practice. This could also include an individual being:  In employment outside of the CCG;  In receipt of secondary income;  In receipt of a grant from a provider;  In receipt of any payments (for example honoraria, one off payments, day allowances or travel or subsistence) from a provider;  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).

Non-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional reputation or Interests 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 special interests e.g. in dermatology, acupuncture etc;  An active member of a particular specialist professional body (although routine GP membership of the Royal College of General Practitioners (RCGP), British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);  An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE);  Engaged in a research role;  The development and holding of patents and other intellectual property rights which allow staff to protect something that they create, preventing unauthorised use of products or the copying of protected ideas; or

 GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices.

Non-Financial This is where an individual may benefit personally in ways which are not directly linked to their Personal professional career and do not give rise to a direct financial benefit. This could include, for Interests 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 in or connection with a voluntary sector organisation;  Suffering from a particular condition requiring individually funded treatment;  A member of a lobby or pressure group with an interest in health and care.

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 (as those categories are described above). For example, this should include:  Spouse / partner  Close family member or relative, e.g. parent, grandparent, child, grandchild or sibling;  Close friend or associate; or  Business partner.

A declaration of interest 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.

NOLAN PRINCIPLES

The 7 principles of public life apply to anyone who works as a public office-holder. This includes people who are elected or appointed to public office, nationally and locally, and all people appointed to work in the civil service, local government, the police, the courts and probation services, non- departmental public bodies and health, education, social and care services.

The seven principles are: a) Selflessness – Holders of public office should act solely in terms of the public interest. b) Integrity – Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family or their friends. They must declare and resolve any interests and relationships. c) Objectivity – Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. d) Accountability – Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this. e) Openness – Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. f) Honesty – Holders of public office should be truthful. g) Leadership – Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

Source: The 14th Report of the Committee on Standards in Public Life (January 2013)

Glossary of commonly used NHS terms (acronyms)

AO / CO Accountable Officer / Chief Officer

A&GEMCSU Arden & GEM Greater East Midlands Commissioning Support Unit

BAF Board Assurance Framework or GBAF – Governing Body Assurance Framework

BCF Better Care Fund

BCP Business Continuity Plan

BME Black Minority Ethnic

CAMHS Child and Adolescent Mental Health Services

CAS Clinical Assessment Service

CAU Clinical Assessment Unit

CCG Clinical Commissioning Group

CFO Chief Finance Officer

CHC Continuing Healthcare

CIP Cost Improvement Plan

CNO/CN Chief Nursing Officer/Chief Nurse

CQC Care Quality Commission

CRHTS Crisis Resolution and Home Treatment Service

DES Direct Enhanced Scheme

DoLS Deprivation of Liberty Safeguards

DPH Director of Public Health

DRN Diabetes Research Network

DTOC Delayed Transfers of Care

EAU Emergency Assessment Unit

E&D Equality and Diversity

EPRR Emergency Preparedness Resilience Response

FOI Freedom of Information

FMR Financial Monitoring Report

FST Federated Safeguarding Team

FYFV Five Year Forward View

GMC General Medical Council

GP General Practitioner

GPSI or GP with a Special Interest GPwSI

HDU High Dependency Unit

HFMA Healthcare Financial Management Association

HSC Health Scrutiny Committee

HWBB Health and Wellbeing Board

HSJ Health Service Journal

HWE Healthwatch England

IAPT Improving Access to Psychological Therapies

IAF Improvement Assessment Framework

IFR Individual Funding Request

IG Information Governance

JHWS Joint Health and Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KPI Key Performance Indicator

LAC Looked After Children

LCHS Lincolnshire Community Health Services NHS Trust

LCFS Local Counter Fraud Specialist

LD Learning Disabilities

LECCG Lincolnshire East Clinical Commissioning Group

LES Local Enhanced Services

LPFT Lincolnshire Partnership NHS Foundation Trust

LTC Long Term Conditions

LWCCG Lincolnshire West Clinical Commissioning Group

MDT Multi-Disciplinary Team

MIU Minor Injuries Unit

MRI Magnetic Resonance Imaging

NHSE NHS England

NHSI NHS Improvement

NIGB National Information Governance Board

NLAG Northern Lincolnshire and Goole NHS Foundation Trust

NLCCG North Lincolnshire Clinical Commissioning Group

NQB National Quality Board

NUH Nottingham University Hospitals NHS Trust

NWA North West Anglia NHS Foundation Trust (previously Peterborough and Stamford Hospitals Foundation Trust, PSHFT)

OOH Out of Hours

OPTUM CSS OPTUM Commissioning Support Services

OTC Over the Counter

PACEF (Countywide) Prescribing and Clinical Effectiveness Group

PAS Patient Administration System

PbR Payment by Results

PCCC Primary Care Commissioning Committee

PCRN Primary Care Research Network

PHB Personal Health Budget

PMS Primary Medical Scheme

QEHKL Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

QIA Quality Improvement Assessment

QIPP Quality, Innovation, Productivity and Prevention

QMC Queens Medical Centre

QOF Quality Outcomes Framework

QPEC Quality and Patient Experience Committee

QRM Quantitative Risk Management

QSG Quality Surveillance Groups

RAG Red, Amber, Green rating

RAID Rapid Assessment, Interface and Discharge

RC Remuneration Committee

RCA Root Cause Analysis

RRR Rapid Response Review

RTT Referral to Treatment

SCR Serious Case Review

SHINE Part of Cancer Research UK

SIRO Senior Information Responsible Officer

SLCCG South Lincolnshire Clinical Commissioning Group

SWLCCG South West Lincolnshire Clinical Commissioning Group

SPA Single Point of Access

STP Sustainability and Transformation Partnership

TDA Trust Development Authority

ULHT United Lincolnshire Hospitals NHS Trust

VFM Value for Money

VSM Very Senior Manager

WTE Whole Time Equivalent

Date of Interest Type of Interest Action taken to mitigate risk From To

Current position (s) Declared Interest- held- i.e. Governing (Name of the Is the interest Name Body, Member Nature of Interest organisation and direct or practice, Employee or nature of business) indirect?

other

Interests

Non-Financial

FinancialInterests

Professional Interests Professional Non-Financial Personal Lay Member, Managed through Conflict of Interest Tracey Latham Green Governance/ Deputy D&T Latham-Green x Policy CCG Chair Business Consultancy Partner 2004 Ongoing

Managed through Conflict of Interest Boston West Academy x Direct School Governor Sep-17 Ongoing Policy Sandra Williamson Chief Finance Officer School

N/A N/A John Turner Chief Officer None

N/A N/A Liz Ball Chief Nurse None

Clinical Leader, Governing Body Lincolnshire & District Managed through Conflict of Interest Dr Seng Keat Ko x Shareholder 2007 Ongoing Member, LECCG Medical Services Policy Prescribing Lead

Clinical Leader, Governing Body Special Interest in Managed through Conflict of Interest Dr Seng Keat Ko General Practice x 2014 Ongoing Member, LECCG Dermatology Policy Prescribing Lead

Clinical Leader, James Street Family Governing Body Practice & Tasburgh Managed through Conflict of Interest Dr Seng Keat Ko x Senior Partner 2004 Ongoing Member, LECCG Lodge Surgery, Policy Prescribing Lead Woodhall Spa Clinincal Leader, East Referral Facilitation Service Managed through Conflict of Interest Dr Seng Keat Ko Optum x Feb-19 Ongoing Lindsey GP Triager Policy

CCG Chair/Clinical GP Partner holding GMS Leader/Chair of Boston contract and various Managed through Conflict of Interest Dr Andrew Doddrell Greyfriars Surgery x 01-Aug-92 Ongoing Locality, Governing enhanced services and AQP Policy Body Member contracts

Provide prison healthcare to CCG Chair/Clinical North Sea Camp. Contract Leader/Chair of Boston Managed through Conflict of Interest Dr Andrew Doddrell North Sea Camp x for 5-7 years with Dec-14 Ongoing Locality, Governing Policy Nottingham South Health Body Member Trust Wife is a Methodist Minister, CCG Chair/Clinical development of primary care Leader/Chair of Boston pastors in Boston area, Managed through Conflict of Interest Dr Andrew Doddrell x Ongoing Locality, Governing providing counselling & Policy Body Member direction to people in difficulty Undertakes ad hoc sessions CCG Chair/Clinical for the Out of Hours service Leader/Chair of Boston (run by LCHS) providing GP Managed through Conflict of Interest Dr Andrew Doddrell Out of hours GP x Ongoing Locality, Governing assessment of patients Policy Body Member

CCG Chair/Clinical Greyfriars receiving support Leader/Chair of Boston Managed through Conflict of Interest Dr Andrew Doddrell x Indirect from Roche to maximise Apr-18 End of 2018 Locality, Governing Policy diabetes care Body Member

CCG Chair/Clinical Leader/Chair of Boston Boston Borough Managed through Conflict of Interest Dr Andrew Doddrell x Medical referee Boston Jun-18 Ongoing Locality, Governing Council Crematorium Policy Body Member

CCG Chair/Clinical Involvement with Boston Leader/Chair of Boston Member Practice within Managed through Conflict of Interest Dr Andrew Doddrell x Neighbourhood Team as Ongoing Locality, Governing Boston Locality Policy part of Better Care Fund Body Member Clinical Leader/Chair of Boston Locality, Health Education East Managed through Conflict of Interest Dr Andrew Doddrell x GP trainer May-95 Ongoing Governing Body Midlands (HEEM) Policy Member

Secondary Care Doctor, Governing Body St Barnabas Hospice Managed through Conflict of Interest Dr David Boldy x Trustee Jan-16 Ongoing Member, PCCC, QPEC Lincolnshire Policy Chair

Secondary Care Doctor, Governing Body Managed through Conflict of Interest Dr David Boldy British Thoracic Society x Member 1986 Ongoing Member, PCCC, QPEC Policy Chair Secondary Care Doctor, Governing Body Mentoring of ULHT Managed through Conflict of Interest Dr David Boldy ULHT x 2010 Ongoing Member, PCCC, QPEC Consultants Policy Chair Secondary Care Doctor, Governing Body University of Managed through Conflict of Interest Dr David Boldy x Teaching Medical Students 2000 Ongoing Member, PCCC, QPEC Nottingham Policy Chair Secondary Care Doctor, Son worked at ULHT as a To be monitored and reviewed with Governing Body Dr David Boldy ULHT Indirect health care support worker 2014 Ongoing Conflicts of Interest Guardian Member, PCCC, QPEC on the Bank regularly Chair Secondary Care Doctor, Governing Body Wife works for Lincoln Managed through Conflict of Interest Dr David Boldy Lincoln Medical School x Indirect Jul-18 Ongoing Member, PCCC, QPEC Medical School Policy Chair Secondary Care Doctor, Governing Body Managed through Conflict of Interest Dr David Boldy ULHT x Indirect Wife works for ULHT Sep-18 Ongoing Member, PCCC, QPEC Policy Chair Secondary Care Doctor, Widening Participation Governing Body Managed through Conflict of Interest Dr David Boldy Lincoln Medical School x Champion, Lincoln Medical Jul-18 01-Jan-19 Member, PCCC, QPEC Policy School Chair Early Years Clinical Teaching Co-ordinator, Secondary Care Doctor, involves organising Governing Body practising clinicians from Dr David Boldy Lincoln Medical School x Aug-19 ongoing To be agreed with Dr Doddrell Member, PCCC, QPEC primary and secondary care Chair to deliver individual teaching sessions for the new curriculum

Deputy Clinical Chair/Clinical Leader, Managed through Conflict of Interest Dr Neal Parkes LADMS (TWMe8) x Direct Chief Executive Officer 31/07/2018 Present Vice-Chair, East Lindsey Policy Locality

Deputy Clinical Chair/Clinical Leader, East Lindsey Medical Managed through Conflict of Interest Dr Neal Parkes x Direct Partner 31/07/2018 Present Vice-Chair, East Lindsey Group Policy Locality

Deputy Clinical Chair/Clinical Leader, Managed through Conflict of Interest Dr Neal Parkes Crossroads Practice x Direct Partner 31/07/2018 Present Vice-Chair, East Lindsey Policy Locality

Deputy Clinical Chair/Clinical Leader, Managed through Conflict of Interest Dr Neal Parkes Vice-Chair, East Lindsey Pertemps Medical x Direct In partnership 31/07/2018 Present Policy Locality, Governing Body

Lay Member, Patient & Brenda Owen None N/A N/A Public Involvement

Clinical Leader and Chair, Skegness & Managed through Conflict of Interest Dr Stephen Savory Spilsby Surgery x Direct GP Partner Year 2010 Ongoing Coast Locality, Policy Governing Body Clinical Leader and Chair Skegness and Health Education East Managed through Conflict of Interest Dr Stephen Savory x GP Trainer 2003 Date Coast Locality, Midlands (HEEM) Policy Governing Body

Clinical Leader and Spilsby Surgery is a core Chair, Skegness & Skegness and Coast member practice of Managed through Conflict of Interest Dr Stephen Savory x Year 2019 Coast Locality, Area GP Network Skegness & Coast PCN Policy Governing Body (Primary Care Network)

Spilsby Surgery is a Clinical Leader and Primary Care shareholder in Primary Care Chair, Skegness and Managed through Conflict of Interest Dr Stephen Savory Lincolnshire Medical x Lincolnshire Medical Year 2016 Ongoing Coast Locality, Policy Services GP Federation Services Ltd (GP Governing Body Federation)

Clinical Leader and Chair Skegness and LECCG area representative Managed through Conflict of Interest Dr Stephen Savory Lincolnshire LMC x Year 2017 Ongoing Coast Locality, Lincolnshire LMC Policy Governing Body

Lay Member Primary Dr Brynnen Massey Care Commissioning x GP Appraiser, NHS England Oct-16 Current Committee (PCCC) Declare and note Lay Member Primary Member of St Andrews Dr Brynnen Massey Care Commissioning x 1997 Current Hospice, Grimsby Committee (PCCC) Declare and note Lay Member Primary Chair of the Lincolnshire Dr Brynnen Massey Care Commissioning x Individual Funding Request Oct-18 Committee (PCCC) (IFR) Panel Declare and note Item 4

GOVERNING BODY PUBLIC MEETING

Minutes of the Public Governing Body meeting held on Thursday, 28 November 2019 at 1.30 pm in The Thoresby Suite, Louth Hospital, High Holme Road, Louth, LN11 0EU

Present: Dr A Doddrell, Clinical Leader, Boston Locality (Chair) Dr S K Ko, Clinical Leader, East Lindsey Locality Dr S Savory, Clinical Leader, Skegness and Coast Locality Mrs E Ball, Chief Nurse Mrs S Williamson, Chief Finance Officer Mrs B Owen, Lay Member - Patient & Public Involvement Dr D Boldy, Secondary Care Doctor

In Attendance: Mrs C Wilson, Corporate/Board Secretary Mrs L Moulder, Healthwatch Mr T McGinty, Consultant in Public Health, LCC Mr T Crowden, Communications Manager, Optum CSS Two Members of the Public

Apologies for Mr J Turner, Accountable Officer, Lincolnshire CCGs Absence: Dr N Parkes, Clinical Leader, East Lindsey Locality Mrs T Latham-Green, Lay Member – Governance Dr B Massey, Lay Member – Primary Care Dr B Sinha, Clinical Leader, Skegness and Coast Locality

Action 94/19 Welcome & Introductions

Dr Doddrell welcomed all those present to the meeting and apologies were noted.

The meeting was noted as not being quorate, due to only three Clinical Leaders being present

Dr Doddrell advised that as we are in an election there is currently a period of purdah, and therefore the management of the meeting would reflect that fact and therefore have an impact on what takes place.

95/19 To receive any Declarations of Pecuniary or Non-Pecuniary Interests

Dr Doddrell reminded members of their obligation to declare any interest they may have on any issues relating to the agenda which might conflict with the business of the CCG.

All declarations listed by members of the Governing Body are detailed in the CCG’s Register of Interests which is available either via the CCG Board Secretary or on the CCG website at the following link:-

Action https://lincolnshireeastccg.nhs.uk/about-us/declaration-of-interests

No additional interests were declared.

96/19 To Receive & Approve the Minutes of the meeting held on 26 September 2019

The minutes of the meeting held on 26 September 2019 were received and approved as a correct record of proceedings.

97/19 To consider any Matters Arising from the previous minutes and review the Action Log

97/19.1 60/19.1 – 25/19 Update on STP: Ongoing. Date to be arranged in due course to present the work on the Lincolnshire Workforce Advisory Board (LWAB) at a future Joint Governing Body meeting. Agreed to keep the item on the action log. Mrs Wilson

97/19.2 60/19.2 – 27/19 – Quality Report on ULHT: Noted that not yet progressed, however a quality visit is scheduled for the following Mrs Ball week and it will be raised at that point. Dr Doddrell advised that he had also raised this with Andrew Morgan.

97/19.3 60/19.3 – Potential Risks – Prior Approval Changes: Mrs Wilson has chased a response and not yet received an answer. She agreed Mrs Wilson to chase again.

97/19.4 60/19.6 – To receive a Quality Report on ULHT: Mr McGinty confirmed that it would be helpful to have observations from primary care in supporting the treatment of sepsis. He advised that the whole of urgent care is standardising on NEWS2 (National Early Warning Score) and the issue will be whether primary care is going to be in a position to able to converse in that language. Further work would therefore need to be progressed on this and he agreed to take this forward with urgent care.

With regard to the review on mortality, Mr McGinty advised that the first stage of the review had been undertaken and the mortality summit, having taken that on board, have changed the way they operate. They will now be looking more widely at what the system is doing around unexpected mortality, and therefore the second stage of the review will not take place as they have already reacted to the first stage by changing the way they are operating.

He advised that, fundamentally, what the review identified was that the read across from the indicators being looked at to the wider understanding of mortality in the population did not work properly and, because of that, the numbers being looked at were not a true and full picture of mortality in Lincolnshire, therefore the methodology was switched slightly.

97/19.5 62/19 – Update on STP: Action completed.

97/19.6 66/19 – Update on Safeguarding and Safeguarding Annual Report: Action completed.

Action

97/19.7 68/19 – Integrated Performance Report: Work is still ongoing and Mrs further detail to be brought to the January 2020 meeting. Williamson

97/19.8 80/19 – Approval of the Better Care Fund Plan 2019/20: Mrs Ball confirmed that this report had been presented to the Health & Wellbeing Board.

97/19.9 86/19 – Integrated Performance Report: Mrs Williamson advised she had not received an update on whether or not there was a workforce issue with regard to Pathlinks, however, Dr Boldy reported on a conversation he had recently with the Pathlinks Consultant. There are currently 4 or 5 Pathologists, and he understood there

should be about 17-18. Four new Pathologists would be commencing in January 2020. In the interim, they have been outsourcing work, and it was hoped that with more staff joining that will have a positive impact on turnaround. It was agreed to keep this on the action log in Mrs Wilson order to keep an eye on it.

98/19 To approve the following Policies:-

 Policy & Procedure for the Recording, Investigating and Management of Complaints, Comments, Concerns and Compliments  Policy for the Development and Control of Patient Group Directions (PGDs)  Commissioning Policy for IVF

As this meeting was not quorate, it was agreed that these Policies would be taken to the QPEC Committees in Common for approval. Mrs Ball

99/19 To receive an Update from the CCG Chair & Chief Operating Officer

Dr Doddrell provided an update to members on the move to a single CCG for Lincolnshire, advising that a letter of authorisation had been received from NHS England with a number of conditions.

Work was now ongoing on progressing through those conditions, which included the development of a new Constitution, a copy of which would be circulated to members in due course.

Dr Doddrell also reported that there are financial pressures in the system and the Finance report later on the agenda would provide the detail on that.

Mrs Owen asked where senior management and the locality will be based in the future, and Dr Doddrell advised that no decision had yet been reached on that, however, discussions were ongoing.

Dr Boldy also queried what would happen if the conditions were not met and approval was not given for a 1 April 2020 date. Dr Doddrell advised that the merger would then be put back for a year and take place in April 2021, however, he advised that Mr Turner was confident that all the conditions could be met.

Action  To note the update.

100/19 To receive an Update on the Move to a Single CCG for Lincolnshire

Paper received for information. Update provided in previous item.

101/19 To receive a System Update – September 2019

Received for information.

102/19 To receive the Update Report from Healthwatch

Mrs Moulder presented the report providing a summary of the patient, carer and user experiences of health and care services in Lincolnshire, and she referred to two individual patient stories that had been shared.

She also referred to some emerging issues by service area which included acute services, cancer services and the community pain management service and the difficulties patients were having relating to that.

Dr Doddrell felt that the report was informative and correlated a lot with what the CCG discuss and hear.

Mrs Ball also advised that the CCG were in close dialogue with Healthwatch, and had a joint meeting with them this week, together with the Chief Nurse of ULHT. She advised that it was always disappointing when standards of care are not met. In terms of the feedback around the CAMHS service, she stated that it was disappointing that the individual’s needs had not been met and therefore there was some key work that needed to be focussed on between the ages of 16 and 25. She stated that generally there is a good CAMHS service in Lincolnshire, and it is rated as outstanding by the CQC, but in this case it had not met that individual’s needs.

Mrs Ball advised that in terms of the CHC service there had been some challenges around the access of CHC into hospitals in the South, and she agreed to feedback on this case to the lead in CHC so that they could address this issue.

Mrs Moulder went on to state that 48% of the comments received were positive, and it was good that people who do contact Healthwatch do not always have bad things to say.

Mrs Owen highlighted that in a number of areas the feedback was very low, for example 4% in social care. Mrs Moulder advised that this was probably because no specific targeting had been undertaken in that area, however Healthwatch would be taking some more work into care homes and therefore that social care commitment will probably be much higher in the future.

Action Dr Boldy referred to the mental health patient history details in which it stated that the mortality rates for Lincolnshire are far higher than acceptable. He queried how much is far higher and what data this related to.

Mrs Moulder advised that she would look into this further to see where this figure had come from, and Mr McGinty agreed to assist to Mrs Moulder/ help clarify this. He also advised that he was not aware of any Mr McGinty material data that would rate Lincolnshire services as being worse than you would expect.

Dr Boldy also queried if Peterborough were aware of the Palliative Care Co-ordinating Centre which is a useful resource to fastrack individuals out of hospital. He also felt that the 20 page fastrack form does seem excessive, and wondered why we are different to other CCGs. Mrs Ball felt that this may be referring to the eligibility form, Mrs Ball and agreed to clarify this.

Mrs Moulder also advised that this Consultant had come to Healthwatch directly. Mrs Ball would address this with the Chief Mrs Ball Nurse in South Lincolnshire to ensure Peterborough were aware of the process.

Dr Doddrell queried if the feedback received on the community pain management service had been fed into the CCG, and Mrs Moulder Mrs Moulder agreed to look into this and feed the information through to Mrs Ball.

The Governing Body agreed:-  To note the update provided.

103/19 To receive a Quality Report on United Lincolnshire Hospital Trust (ULHT)

Mrs Ball presented the report providing an oversight to the system’s response to ULHT’s latest CQC unannounced inspection which commenced on 11 June 2019, and the Well Led inspection which commenced on 15 July 2019.

She referred to the areas of improvement expected around sepsis, the children and young people’s pathway through the Emergency Department and the ED access for children and young people. There has been some progress around these and there are some attachments to the report detailing that progress.

Mrs Ball also attended the System Improvement Board (SIB) and there was a presentation on the Trust progress against those actions, and also there is an update on that going to QPEC to allow for more detailed discussion.

The SIB has the oversight of all of the programmes, and they are changing the way they are reporting. Page 4 of the report and the current Amber Green ratings, will be changed into a new quality and safety improvement plan which will be assured through the internal governance processes that ULHT are strengthening.

Action Mrs Ball advised that the next SIB will be a formal Quality Summit taking place next month, which will be attended by herself, Mr Turner, and possibly a Chair of a CCG.

She stated that in terms of the performance report there has been improvements in the in-hospital mortality, however, out of hospital mortality is still higher than it should be and there is a whole system approach on looking to improve it.

There also continues to be issues around falls and management of serious incidents, and there are a number of investigations outstanding, with an increase in never events.

Dr Boldy highlighted that the Trust had a backlog of serious incidents two years ago, and queried if they were still on top of that or is it growing again. Mrs Ball advised that the Trust were still on top of these, however, inadvertently it had caused a backlog elsewhere in the system. The serious incidents were being closed on StEIS, however, this was resulting in some outstanding follow ups on the Datix system. This will be discussed at the next Serious Incident meeting to come up with a solution.

Dr Doddrell also asked if there were any particular trends with the serious incidents. Mrs Ball advised that the type of information that goes into QPEC is more of an analysis of the trends of serious incidents across the whole of the system. However, within ULHT there is some internal knowledge of where there are also some areas that are known to the CQC so those are the ones that are kept an eye on.

Dr Boldy asked if any learning from incidents takes account of primary care factors, and, if so, how does that learning get back into primary care. Mrs Ball advised that serious incident meetings had previously had GP input into them, however this had not happened for a while but was in the process of being resurrected so that there is a link to the general practice element that will triangulate that learning.

Finally, Dr Boldy felt that it was worth noting that ULHT has done very well with their Duty of Candour, and this was noted by members.

The Governing Body agreed:  To note the report and the update provided.

104/19 To receive the Integrated Performance Report

Mrs Williamson presented the report providing an overview of performance statistics for Lincolnshire STP against the NHS Oversight Framework and other NHS performance requirements, including the NHS Constitution pledges and Long Term Plan.

She advised that the key things to note are that within A&E the target is still being missed and has been for a few months now, even against the plan that had been set back in October. Also, the cancer performance and, in particular, the 62 days is falling behind what has been set as the trajectory.

Action Mrs Williamson further advised that the CCGs had an assurance meeting with NHSE the previous week, and in terms of the A&E performance and Cancer 62 day, Recovery Plans will be put in place.

Mrs Williamson also reported on some good news, and despite having a few patients, the 52 week standard is doing well and has been commended, together with the diagnostic standard as a Lincolnshire system.

A number of questions/queries were raised by members as follows:-

 26+ pathways reduction standard - Dr Boldy noted that the current performance was 3169 showing as green, but the target had not been met. Mrs Williamson confirmed that this shows it is going in the right direction, but the target is still not being met. Dr Boldy queried how realistic this target was, and Mrs Mrs Williamson agreed to follow this up. Williamson

 ‘Activity compared to plan’ – Dr Boldy noted that there were fewer first outpatients and fewer follow-ups which is good news, however he was concerned that this may transfer work into primary care. Mrs Williamson advised that the work being undertaken on follow-ups is about the activity being offered in a different way and not about transferring it. Individuals are having unnecessary follow-ups in secondary care, and implementation has started to reduce per specialty. The ambition is a 30% reduction over 4 years, which may mean having to look at alternative pathways.

 Outpatient letters – Dr Boldy also queried the speed of the letters from secondary care outpatient appointments to primary care, and Dr Savory advised that the Trust are trialling the new digital dictation system in the specialities with the longest wait which apparently has gone very well. They are hoping to have all specialties using it by June of next year.

 Non-elective admissions - Dr Boldy expressed his concern around the increase, and Mrs Williamson advised that a steady rise has been seen and there is a deep dive review that is being undertaken to see what is driving the admission pathways.

 A&E 4 hour wait - Dr Boldy queried if there was any divergence in performance between ULHT and NLAG. Mrs Williamson agreed to look into this as she did not have that Mrs information to hand. Williamson

Dr Doddrell felt that whatever primary care could do to try to bring this pressure out of the system it ought to be trying to do, and firstly it would be useful to make everyone aware of the current pressures. He stated that there are many ways clinicians can manage things out in primary care. He had also noted that ULHT had asked the Older Adult’s Team to see some patients who potentially could be long stay and help to plan to get them out.

Action Mrs Moulder asked if the triage system in front of A&E is working and Mrs Williamson confirmed that the urgent care streaming service has been very successful. Mrs Williamson confirmed that a lot of work has been done at the front end and now it is about reviewing pathways and admissions.

It was also queried if the streaming figures were included in the A&E 4 hour performance. Mrs Williamson did not think this was included Mrs but would check with James Singleton. Dr Savory also asked for Williamson clarity on whether or not the data included the Urgent Care Treatment Centres at Skegness & Louth. Mrs Williamson would also check on this.

Dr Boldy referred to the plans to achieve an average 10 day length of stay by April 2020 for stroke, however, he had not seen the proposed hyper-acute model for stroke. Due to purdah, it was agreed that this would be revisited after the conclusion of the election and discussed Mrs at the next meeting. Williamson

He also referred to frailty, in which it stated that plans are in place to increase the number of patients within care homes who have an advanced care and escalation plan during 2019/20, and he asked by how much. Mrs Ball agreed to clarify this and let Dr Boldy know what Mrs Ball the target is.

Dr Doddrell also asked that this be linked in with what the PCNs have to do over the next 12 months because there is an enhanced service around looking after individuals in Nursing Homes and he would not want there to be duplication.

Dr Boldy queried that, if the number of first outpatients is down and the number of follow-ups is down, then he was not sure why the Referral to Treatment Times (RTT) were not improving, and he would like to understand this further. Mrs Williamson felt that if it was broken down between the admitted pathway and the non-admitted, then that might help to understand it further. Dr Boldy also referred to ULHT moving all their orthopaedics surgery to Grantham, and wondered if there was an update on how effective that had been in reducing cancelled operations. Mrs Williamson advised that this Mrs information had been shared in ULHT’s public Board papers and Williamson agreed to add the information to this report in the future.

The Governing Body agreed:  To note the report and the current performance.

105/19 To receive the Governing Body Assurance Framework (GBAF)

Item deferred.

106/19 To receive the Financial Monitoring Report

Mrs Williamson presented the report providing an update on the financial position for Lincolnshire East CCG as at 31 October 2019. It was noted that the position is consistent with that reported to the NHS England Area Team.

Action She advised that the CCG is still projecting to achieve the £1m surplus at the end of March 2020, however, the year to date position shows that the CCG is £298k away from target at Month 7. She advised that this was mostly to do with acute activity being higher than plan.

Mrs Williamson further advised that prescribing is a high risk area and is currently being reviewed. There could be a forecast overspend of £1.7m by year end, and some of that is to do with the Category M price increases, which is a national concern. There is a review to look at what further work can be done on prescribing.

From a QIPP perspective, the CCG is on track to achieve £8.6m efficiencies by the end of March with a programme set at the beginning of the year of £10.7m.

The Governing Body agreed:  To note the update provided.

107/19 To receive an update on Public Health Issues

Mr McGinty provided an update to the Governing Body on key Public Health issues as follows:-

 Flu – ongoing problems with the supply of vaccines, and the childhood nasal vaccines of particular concern at the moment which are in scarce supply. Therefore, a low uptake will be seen this year now.  One flu outbreak in a care home in Lincolnshire, which was in Lincolnshire East, and also a cluster seen around a couple of schools in Boston, however this did not result in an outbreak. It was in 3 different childcare settings with children from the same family. He further advised that some of the cases had already been immunised before they became ill and they were still quite poorly with the flu as well. Mr McGinty advised that the flu season had not been called as yet, although a lot of cases were still being seen in Lincolnshire.  Cancer screening programmes – a number of performance problems with the programmes for Lincolnshire patients. Breast screening programme difficulty with turnaround times. Women are not being screened in line with the recommended screening round length because they cannot get them in quickly enough. Cervical screening has still not managed to get to the 4 week turnaround time promised for cervical screens, and if anything the performance has deteriorated. Since they have moved to the HPV first programme, it has become worse despite being told it would improve performance. There is a formal improvement plan in place with NHSE for both of these screening programmes.  Gram negative bacteraemia infections – just about to start a geographical mapping exercise, and numbers are again going in the wrong direction. Practices will be asked to help out on this.

Action  Emergency Planning Response & Resilience – all of the local NHS organisations have achieved substantial compliance or above on the core standards assessment.  Falls Response Service commissioned from LIVES has now gone countywide and is continuing to have good results. As a result of the first part of the programme, Public Health has commissioned a follow on guaranteed next day visit from Social Care organisations, and will see whether this makes a difference.  Place based discussion – work undertaken with two main District Councils that cover the East as a place. There is a good strategic partnership with Boston Borough Council, with some really good, tightly focussed priorities. Now getting into preliminary conversations with East Lindsey to see how they might want to step up with that kind of focussed activity. They also have a new Corporate Strategy around Ageing Well.

Mrs Williamson queried how the CCG could link into that Mrs programme, and it was agreed that further conversations Williamson/ would take place on this outside of the meeting. Mr McGinty

The Governing Body agreed:  To note the update provided.

108/19 Items for Noting, Reference and Information

108/19.1 – To receive the Exception Report from the Quality & Patient Experience Committee (QPEC) held on 19 June 2019: Received for information.

108/19.2 – To receive the Exception Report from the Primary Care Commissioning Committee meeting held on 3 October 2019: Received for information.

108/19.3 – To receive the Exception Report from the Audit Committee held on 4 September 2019: Received for information.

108/19.4 – To receive the Exception Report from the Boston Executive Group held on 12 September 2019: Received for information.

108/19.5 – To receive the Exception Report from the Finance & Performance Committee held on 25 July 2019: Received for information.

108/19.6 – To receive the Exception Report from the Skegness & Coast Executive Group held on 15 August & 10 October 2019: Received for information.

108/19.7 – To receive the Minutes of the Health Scrutiny Committee for Lincolnshire held on 18 September 2019: Received for information.

108/19.8 – To note the MP Correspondence Log: Received for information.

Action 108/19.9 – To note the Freedom of Information Log: Received for information.

108/19.10 – To note the Caldicott Monitoring Log: Received for information.

109/19 To consider any potential risks identified during the meeting

Dr Boldy asked that the risk of purdah delaying everything for four to six weeks should be noted.

110/19 Questions from the Public

The following questions were received from members of the public present at the meeting:

 Question from a GP present around a death audit undertaken at their practice and concerned that of the 26 deaths, 10 were in hospital but no detail provided about how they died.

Dr Savory responded and advised that historically there had been a problem with delays in death notifications when they were issued from the wards as part of the electronic discharge. The new process is that the death notifications will come from the bereavement office and they will aim to get them out the same day. However, they will not necessarily have the clinical information from the wards, and practices will need to contact the wards. He agreed to feed this concern Dr Savory back into the next EDD meeting.

 Question also raised about, if the population of Lincolnshire is rising, how quickly does the finance come with that to support more services, and Mrs Williamson provided a response.

111/19 Date and Time of Next Meeting

The next Governing Body meeting will take place on Thursday, 23 January 2020 at 1.30 pm at The Golf Hotel, The Broadway, Woodhall Spa, Lincs, LN10 6SG

The Chair closed the meeting at 3.30 pm

Item 5

GOVERNING BODY ACTION LOG – PUBLIC MEETING

ACTIONS FROM 28 NOVEMBER 2019 MEETING

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken 25 July 2019 60/19.1 25/19 – Update on STP: Members agreed that it would still be helpful to invite Mrs Ball TBC Date to be set in due Maz Fosh from LCHS to a future Governing Body course. To keep on meeting to the present the work of the Lincolnshire action log. Workforce Advisory Board (LWAB). Mrs Ball to take this forward.

25 July 2019 60/19.2 27/19 – Quality Report on ULHT: Dr Doddrell also referred to the action raised by Dr Mrs Ball Oct/Nov Ongoing. Howarth regarding issues of getting through on the 2019 Quality visit telephone to the department at Pilgrim. Mrs Ball to scheduled for chase and send out as a post-meeting note. w/c 2 December and will be raised again

25 July 2019 60/19.3 Potential Risks – Prior Approval Changes: Noted that this issue was in the process of being Mrs Wilson Nov 2019 Mrs Wilson to chase added to the risk register. Dr Doddrell queried how a response this was being analysed and suggested the question Emailed 11.10.19 was posed with the LMC. In Progress – An email from Karen Byfield explains that

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken there has been some audit review work done. There is also a meeting in place on 5th September to discuss these issues.

25 July 2019 68/19 To receive the Integrated Performance Report: Mrs Williamson to find out the national figures for A&E Mrs November Work is still ongoing activity and admissions and to look into what the Williamson 2019 and further detail to impact of change in services in General Practice has be brought to the on A&E. A report to be brought back in due course. January 2020 Mrs Williamson working with Ruth Cumbers on this. meeting

26 September 86/19 To receive the Integrated Performance Report: 2019 With regard to Cancer 62 day, Dr Boldy raised a query Mrs 31 October Dr Boldy provided an regarding improving the pathology turnaround time at Williamson 2019 update at the ULHT, and asked whether this was a workforce issue November meeting. with Pathlinks. Mrs Williamson agreed to look into this. To keep on action log to monitor

28 November 98/19 To approve Policies: 2019 These Policies will be taken to the next QPEC Mrs Ball 12 December Actioned Committees in common for approval. 2019 12.12.19

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken 28 November 102/19 Update Report from Healthwatch: 2019 Mortality Rates for Lincolnshire – Mrs Moulder to look Mrs Moulder/ 31 December into this further to see where this figure had come Mr McGinty 2019 from, and Mr McGinty agreed to assist to help clarify this.

Dr Boldy also queried if Peterborough were aware of Mrs Ball 31 December the Palliative Care Co-ordinating Centre which is a 2019 useful resource to fastrack individuals out of hospital. He also felt that the 20 page fastrack form does seem excessive, and wondered why we are different to other CCGs. Mrs Ball felt that this may be referring to the eligibility form, and agreed to clarify this.

Mrs Moulder also advised that this Consultant had Mrs Ball 31 December come to Healthwatch directly. Mrs Ball would address 2019 this with the Chief Nurse in South Lincolnshire to ensure Peterborough were aware of the process.

Dr Doddrell queried if the feedback received on the Mrs Moulder 31 December community pain management service had been fed 2019 into the CCG, and Mrs Moulder agreed to look into this and feed the information through to Mrs Ball.

28 November 104/19 Integrated Performance Report: 2019 26+ pathways reduction standard - Dr Boldy noted that Mrs 31 December the current performance was 3169 showing as green, Williamson 2019 but the target had not been met. Mrs Williamson confirmed that this shows it is going in the right

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken direction, but the target is still not being met. Dr Boldy queried how realistic this target was, and Mrs Williamson agreed to follow this up.

A&E 4 hour wait - Dr Boldy queried if there was any Mrs 31 December divergence in performance between ULHT and NLAG. Williamson 2019 Mrs Williamson agreed to look into this as she did not have that information to hand.

It was also queried if the streaming figures were Mrs 31 December included in the A&E 4 hour performance. Mrs Williamson 2019 Williamson did not think this was included but would check with James Singleton. Dr Savory also asked for clarity on whether or not the data included the Urgent Care Treatment Centres at Skegness & Louth. Mrs Williamson would also check on this.

Dr Boldy referred to the plans to achieve an average Mrs 23 January 10 day length of stay by April 2020 for stroke, Williamson/ 2020 however, he had not seen the proposed hyper-acute Mrs Wilson model for stroke. Due to purdah, it was agreed that this would be revisited after the conclusion of the election and discussed at the next meeting.

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken know what the target is.

Dr Boldy queried that, if the number of first outpatients Mrs 23 January is down and the number of follow-ups is down, then he Williamson 2020 was not sure why the Referral to Treatment Times (RTT) were not improving, and he would like to understand this further. Mrs Williamson felt that if it was broken down between the admitted pathway and the non-admitted, then that might help to understand it further. Dr Boldy also referred to ULHT moving all their orthopaedics surgery to Grantham, and wondered if there was an update on how effective that had been in reducing cancelled operations. Mrs Williamson advised that this information had been shared in ULHT’s public Board papers and agreed to add the information to this report in the future.

28 November 107/19 Update on Public Health Issues: 2019 East Lindsey Corporate Strategy around Ageing Well Mrs – Mrs Williamson queried how the CCG could link into Williamson/ that programme, and it was agreed that further Mr McGinty conversations would take place on this outside of the meeting.

28 November 110/19 Questions from the Public: 2019 Question from a GP present around a death audit undertaken at their practice and concerned that of the 26 deaths, 10 were in hospital but no detail provided about how they died.

Date of Ref Decision/Action Required Lead Due Date Progress/ Governing Body Action Taken Dr Savory responded and advised that historically there had been a problem with delays in death notifications when they were issued from the wards as part of the electronic discharge. The new process is that the death notifications will come from the bereavement office and they will aim to get them out the same day. However, they will not necessarily have the clinical information from the wards, and practices will need to contact the wards. He agreed to Dr Savory TBC feed this concern back into the next EDD meeting.

GOVERNING BODY MEETING

Date of Meeting: 23 January 2020 Agenda item: 7a

Title of Report: Creating the new Lincolnshire CCG Report Author and Title: Jules Ellis-Fenwick, CCG Corporate Board Secretary/Manager, SWL/SLCCGS Appendices: Draft Constitution for the new CCG

1. Purpose of the Report (including link to objectives)

To provide a progress update on the development of the new Lincolnshire CCG.

2. Recommendations

The Governing Body is asked to note the latest position in terms of the development of the new Lincolnshire CCG, including key governance documents such as the draft Constitution.

3. Executive Summary In July 2019 each of the four Lincolnshire CCGs Governing Bodies received a paper at their respective meetings seeking their approval to establish a single Lincolnshire CCG by 1 April 2020 and to approve the proposed name of the new CCG. All four CCG Governing Bodies approved the recommendations, subject to approval/support being obtained by each of the CCG memberships. During September 2019 all four Lincolnshire CCGs Memberships approved the move to establish a single Lincolnshire CCG by 1 April 2020 and approved the proposed name of the new CCG (NHS Lincolnshire CCG).

The application to become a single Lincolnshire CCG was submitted to NHSEI by the deadline date of 30th September. A Panel meeting was then held with NHSEI and CCG representatives on the 9th October 2019. On 18th October 2019 NHSEI confirmed approval ‘in principle’ for the four Lincolnshire CCGs to merge from 1 April 2020.

This report provides an update on progress against a number of areas including: Development of the new CCG Constitution, Staff, Property, Assets and Liability Transfers, Recruitment to Governing Body roles and Staff Engagement and Consultation.

Constitution

The Constitution for the Lincolnshire CCG has been developed based on the new NHS England model template. To date two drafts have been submitted to NHS England for review and feedback - Comments received on the version submitted at the end of September have been incorporated and the latest version was sent through on 31st December 2020. Feedback from that version is currently awaited.

The initial draft Constitution was shared with the Membership of the four Lincolnshire CCGs during November and December 2019 and comments received have been incorporated where appropriate. The version submitted to NHSE/I on 31st December has also been shared with the Membership for further comments/sign off by close of play on 24th January 2020, as the final ‘draft’ Constitution has to be submitted to NHSE/I by no later than 31 January 2020.

Services commissioned and provided by: 1 South Lincolnshire CCG, South West Lincolnshire CCG, Lincolnshire West CCG, Lincolnshire East CCG

Regular updates and versions of the draft Constitution have also been presented to the Lincolnshire Joint Committee who has oversight of the governance arrangements for the development of the new Lincolnshire CCG. Regular updates have also been considered by the Merger Project Group and the development of the Constitution for the new CCG is a key element of the Merger Programme Plan.

The latest version of the draft Constitution is attached for the Governing Bodies information.

Staff, Property, Assets and Liability Transfers

NHSE/I has issued documentation entitled ‘CCG Mergers Preparation Phase Guidance and Templates’ and this addresses the following areas:

Staff Transfer Scheme (this relates to the movement of staff from the existing CCGs into the new CCG). Property Transfer Scheme (this relates to the movement of responsibility and ownership of all ‘property’ (including anything from buildings to contracts) from the existing CCGs into the new CCG.

This information is being collated through the Merger Project Group.

Recruitment to Governing Body roles

The recruitment process to appoint a Chair to the new Lincolnshire CCG commenced in early December with a closing date for applications identified as 23rd December 2019. The date for the interviews is Tuesday, 21st January 2020.

The recruitment process to appoint five Non-Executive Directors (known constitutionally as Lay Members) commenced in mid-December and the closing date for applications is Friday, 17th January 2020. A date for interviews has not yet been arranged as this will be dependent on the appointment of the CCG Chair who will need to be involved in the process.

The Director of Finance and Contracting role was advertised in early December and interviews held on the 19th December 2019. Mr Matt Gaunt has been appointed to the role of Director of Finance and Contracting. A start date for Mr Gaunt has yet to be agreed.

The Director of Nursing post was advertised internally and interviews were held on 6th January 2020. The post was not recruited to and has now been advertised on NHS Jobs. Hunters Healthcare is supporting the recruitment process.

The recruitment process for the appointment of the Secondary Care Doctor is due to commence in the next few weeks, with a view to having a suitable candidate appointed by the end of February.

The four Chief Operating Officers (COOs) have been appointed to as set out below:

• Mrs Sarah-Jane Mills, West Locality • Mrs Clair Raybould, South West Locality • Mr Andy Rix, South Locality • Mrs Sandra Williamson, East Locality

Staff Engagement and Consultation

Staff members have been made aware of the merger and its progress through regular staff briefings held on Monday mornings and staff members have had the opportunity to ask questions through various channels, including two staff engagement events held on 11th July 2019 and 31st October 2019.

Following the first event a Staff Engagement Group was established to review staff views and suggestions which informed the second event on 31 October 2019. The feedback from the October event has been considered and will inform the next event which is planned to take place in March 2020.

Services commissioned and provided by: 2 South Lincolnshire CCG, South West Lincolnshire CCG, Lincolnshire West CCG, Lincolnshire East CCG

As part of the move to establish a new CCG a formal consultation process with staff is required. The Consultation document for the creation of a new CCG and organisational structure for NHS Lincolnshire CCG was circulated to all staff on Monday, 13th January 2020. The consultation process will close on 12th February 2020.

Staff members have been encouraged to provide feedback through a variety of channels including forthcoming staff events, staff briefings, Line Manager 1:1’s, executive meetings, directly to Mr Turner, Chief Officer or through HR and union representatives.

Feedback received will be considered prior to finalisation of the organisational structure.

The Governing Body is asked to note progress to date.

4. Management of Conflicts of Interest Not applicable.

5. Finance, QIPP and Resource Implications No specific implications

6. Legal/NHS Constitution Considerations The new CCG Constitution will need to be based on the 2018 model constitution template as otherwise it will not be approved by NHS England.

7. Analysis of Risk including Assessments The risk of not having a fully developed and signed off Constitution by the Members is a risk to the establishment of the new CCG and this has been included on the Programme Plan Risk Register.

Please state if the risk is on the CCG Risk Register. Yes √ No

8. Outline engagement – clinical, stakeholder and public/patient Not applicable.

9. Outcome of Impact Assessments Not applicable.

10. Assurance Departments/Organisations who will be affected have been consulted Insert details of the departments you have worked with or consulted during the process:

Finance Commissioning Contracting Medicines Optimisation Clinical Leads Quality Safeguarding Other √

11. Report previously presented at: Not applicable.

12. For further information or for any enquiries relating to this report, please contact Jules Ellis-Fenwick – [email protected]

Services commissioned and provided by: 3 South Lincolnshire CCG, South West Lincolnshire CCG, Lincolnshire West CCG, Lincolnshire East CCG

NHS LINCOLNSHIRE CLINICAL COMMISSIONING GROUP

DRAFT CONSTITUTION

Document Control Sheet

Document Title Draft new CCG Constitution Version 5.0 Status Draft Authors Jules Ellis-Fenwick, CCG Corporate Board Secretary Date 4th July 2019

Document history Version Date Author Comments 1 July 2019 Jules Ellis-Fenwick, CCG First draft for review Corporate Board Secretary, SWL and SLCCGs 2 August 2019 Jules Ellis-Fenwick, CCG Second draft for review Corporate Board Secretary, SWL and SLCCGs 3 September 2019 Jules Ellis-Fenwick, CCG Third draft for review Corporate Board Secretary, SWL and SLCCGs 4 October 2019 Jules Ellis-Fenwick, CCG Fourth draft for review Corporate Board Secretary, SWL and SLCCGs 5. December 2019 Jules Ellis-Fenwick, CCG Fifth draft for review Corporate Board Secretary, SWL and SLCCGs

CONTENTS

1 Introduction ...... 6 1.1 Name ...... 6 1.2 Statutory Framework ...... 6 1.3 Status of this Constitution ...... 7 1.4 Amendment and Variation of this Constitution ...... 7 1.5 Related documents ...... 7 1.6 Accountability and transparency ...... 8 1.7 Liability and Indemnity ...... 10

2 Area Covered by the CCG ...... 11

3 Membership Matters ...... 13 3.1 Membership of the Clinical Commissioning Group ...... 13 3.2 Nature of Membership and Relationship with CCG ...... 17 3.2 Speaking, Writing or Acting in the Name of the CCG ...... 17 3.4 Members’ Rights ...... 17 3.5 Members’ Meetings ...... 18 3.6 Practice Representatives ...... 18

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...... 19 4.4 Authority to Act: the Governing Body ...... 20

5 Procedures for Making Decisions ...... 20 5.1 Scheme of Reservation and Delegation ...... 20 5.2 Standing Orders ...... 20 5.3 Standing Financial Instructions (SFIs) (Delegated Financial Authority Limits) ...... 20 5.4 The Governing Body: Its Role and Functions ...... 21 5.5 Composition of the Governing Body ...... 22 5.6 Additional Attendees at the Governing Body Meetings ...... 22 5.7 Appointments to the Governing Body ...... 23 5.8 Committees and Sub-Committees ...... 23 5.9 Committees of the Governing Body ...... 23 5.10 Collaborative Commissioning Arrangements ...... 24

5.11 Joint Commissioning Arrangements with Local Authority Partners………… 26 5.12 Joint Commissioning Arrangements - Other CCGs…………………………….27 5.13 Joint Commissioning Arrangements with NHS England ……………………….29

6. Provisions for Conflict of Interest Management and Standards of Business Conduct ...... 30 6.1.Conflicts of Interest ...... 30 6.2.Declaring and Registering Interests ...... 31 6.3Training in Relation to Conflicts of Interest ...... 32 6.4Standards of Business Conduct ...... 32

Appendix 1: Definitions of Terms Used in This Constitution ...... 33

Appendix 2: Committee Terms of Reference ...... 36

Appendix 3: Standing Orders ...... 53

Appendix 4: Delegated Financial Authority Limits ...... 89

(including Annex 1 and Annex 2)

1 Introduction

1.1 Name

The name of this Clinical Commissioning Group is NHS Lincolnshire 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 our functions or that there is a significant risk that it will fail to do so. 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 – to be inserted

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 – to be inserted

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

b) where in the circumstances set out in legislation NHS England varies the Constitution other than on application by the CCG.

1.4.2 c) The Accountable Officer may periodically propose amendments to the Constitution 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;  At least half (50%) of all the Governing Body Members formally request that the amendments be put before the membership for approval.

1.4.3 The CCG members will be asked to routinely confirm the current Constitution annually at the Annual Public Meeting.

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. With the exception of the Standing Orders and the Delegated Financial Authority Limits, these documents do not form part of the Constitution for the purposes of 1.4 above. They are the CCG’s:

a) 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. b) Prime financial policies – which set out the arrangements for managing the CCG’s financial affairs. These are available in the Governance Handbook. c) The CCG Governance Handbook – which includes:

 Standards of Business Conduct Policy – which includes the arrangements the CCG has made for the management of conflicts of interest; 7

 The Scheme of Reservation and Delegation (SoRD);  Non-Statutory Committee Terms of Reference  Prime Financial Policies 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 including  CCG Governance Handbook;  CCG Policies

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 it 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;

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 Communications and Engagement Strategy. Further information can be found on the following website – to be inserted h) When discharging its duties under section 14Z2, the CCG will ensure that it will make arrangements to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements by:

i. Appointing a member of the Governing Body to oversee public and patient involvement;

ii. Delegating responsibility to its Governing Body and monitor its progress;

iii. Developing and delivering a Communications and Engagement Strategy which builds continuous and meaningful engagement with the public, patients and carers to influence the shaping of services and improve the health of people in Lincolnshire including:

 working closely with seldom heard groups to ensure they have a voice;  using local and national patient experience data and information to inform our work;

 engaging all CCG practices, including GPs and Practice Managers, and CCG staff in the development and ongoing work of the CCG to ensure they are involved in the core business and related work streams;  support the development of relationships with key stakeholders to ensure partnership working and involvement;  developing core materials and mechanisms for ongoing two-way communications between the CCG and public to allow continual feedback in commissioning decisions;  paying due regard to latest legislation, regulations, guidance and best practice;  engaging with the local authority health overview and scrutiny Committee;  meet annually in public to present an Annual Report which is then published;  produce Annual Accounts which are externally audited;  publish a clear complaints process;  Comply with the Freedom of Information Act 2000 and with the Information Commissioner Office requirements regarding the publication of information relating to the CCG;  provide information to NHS England as required; and  be an active member of the local Health and Wellbeing Board(s).

1.6.2 In addition to these statutory requirements, the CCG will demonstrate its accountability by publishing useful documents and information on its website at - to be inserted

a) The CCG’s policies and procedures; b) Annual reports and Governance Statements; c) Minutes of public meetings of the Governing Body; d) Relevant equality and diversity documents and information and comply with the Public Sector Equality Duty; e) Relevant business resilience and emergency planning documents and information; f) Patient information documents, including notices of any public engagement event; g) Other communications issued by the CCG, including the clinical commissioning strategy, the financial plan and notices of procurement, public consultations, reports, Governing Body meetings dates, venues and papers, and; h) Details of the CCG’s key strategic priorities and plans; i) Expenditure over £25,000; j) Register of Interests; k) Gifts and Hospitality Register; l) Register of Procurements decisions. 1.6.3 The Governing Body of the CCG will throughout the year have an ongoing role in reviewing the CCG’s governance arrangements, to ensure that the CCG continues to reflect the principles of good governance. 1.6.4 The CCG may use other means of communication, including circulating information by post, electronic methods or making information available in venues or services accessible to the public.

1.6.5 The Statement of Principles of Lincolnshire CCG in respect of public involvement are: i) We will work in partnership and involve local people, partners and staff at all stages in planning, shaping, designing and delivering services, and in setting priorities for Lincolnshire. We will make the involvement of people central to everything we do and we aim to make it as easy as we can for people to be involved and to actively include them in ways that are meaningful and give real opportunities to influence.

ii) We will also tell people how their involvement has influenced decisions. Prioritising local health needs may mean that on occasions we are not able to do what people want, if that happens we will explain why and be held to account for our decisions.

iii) We aim to involve and engage local people through ongoing engagement and through project engagement, including through the following mechanisms:

• Work in partnership with Healthwatch Lincolnshire.

• Communications and engagement network – a map and contacts database for the CCG across Lincolnshire that link to patients and the public to ensure a mechanism for two-way communication into and out from the CCG to existing groups.

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. 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.

No Member or former Member, nor any person who is at any time a proprietor, officer or employee of any Member of 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.

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 CCGs’ business, provided that the person indemnified shall not have acted recklessly or with gross negligence.

2 Area Covered by the CCG

2.1.1 An illustration of the geographical area covered by Lincolnshire CCG is detailed below:

2.1.2 The CCG is made up of registered patients of Member practices, served by the following District and Borough Councils and led by one Local Authority which are fully coterminous and are supported by the registered primary care practice populations in Lincolnshire:  the County Council of Lincolnshire  the City Council of Lincoln  the Borough of Boston  the District of East Lindsey  the District of West Lindsey  the District of South Holland  the District of South Kesteven  the District of North Kesteven  the District of Sleaford Town

2.1.3 In Lincolnshire County Council Local Authority the CCG covers the following Lower Layer Super Output Areas (LSOAs):

To be inserted.

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 Practice Address Number ABBEY MEDICAL PRACTICE C83051 95 Monks Road, Lincoln, LN2 5HR

ABBEYVIEW SURGERY C83617 Crowland Health Centre, Thorney Rd, Crowland, Peterborough, PE6 0AL BEACON MEDICAL PRACTICE C83019 Churchill Avenue, Skegness, PE25 2RN BEECHFIELD MEDICAL CENTRE C83003 Beechfield Gardens, Spalding, PE11 1UN BILLINGHAY MEDICAL PRACTICE C83030 39 High St, Billinghay, Lincoln, LN4 4AU BINBROOK SURGERY C83643 Back Lane, Binbrook, LN8 6ED

BIRCHWOOD MEDICAL PRACTICE C83082 Jasmin Road, Lincoln, LN6 0QQ

BOULTHAM PARK MEDICAL C83014 Boutham Park Road, Lincoln, LN6 PRACTICE 7SS

BOURNE GALLETLY PRACTICE C83054 40 North Rd, Bourne, PE10 9BT TEAM BRANSTON & HEIGHINGTON C83029 Station Road, Branston, Lincoln, LN4 FAMILY PRACTICE 1LH

BRANT ROAD & SPRINGCLIFFE C83078 291 Brant Road, Lincoln, LN5 9AB SURGERY BRAYFORD MEDICAL PRACTICE C83626 Newland Health Centre, 34 Newland, Lincoln, LN1 1XP

CAISTOR HEALTH CENTRE C83613 Dale View, Caistor, LN7 6NX

CASKGATE STREET SURGERY C83044 3 Caskgate Street, Gainsborough, DN21 2DJ

CAYTHORPE & ANCASTER C83020 12 Ermine St, Ancaster, Grantham, MEDICAL PRACTICE NG32 3PP CHURCH WALK SURGERY C83062 Drury Street, Metheringham, Lincoln, LN4 3EZ

CLEVELAND SURGERY C83018 Vanessa Drive, Gainsborough, DN21 2UQ

CLIFF HOUSE MEDICAL PRACTICE C83073 82 Burton Road, Lincoln, LN1 3LJ

COLSTERWORTH SURGERY C83053 Back Ln, Colsterworth, Grantham, NG33 5NJ CROSSROADS MEDICAL PRACTICE C83637 Lincoln Road, North Hykeham, LN6 8NH

DR LONGFIELD AND PARTNERS C83067 The Medical Centre, 10 Valley Lane, Long Bennington, NG23 5FR DR SINHA & PARTNERS C83049 Church End, Old Leake, Boston, PE22 9LE EAST LINDSEY MEDICAL GROUP C83056 153 Newmarket, Louth, LN11 9EH

GLEBE PARK SURGERY C83079 17 Montaigne Crescent, Lincoln, LN2 4QN

GOSBERTON MEDICAL CENTRE C83036 Low Gate, Gosberton, Spalding, PE11 4NL GREYFRIARS SURGERY C83059 South Square, Boston, PE21 6JU

HAWTHORN MEDICAL PRACTICE C83045 Hawthorn Road, Skegness, PE25 3TD

HEREWARD MEDICAL CENTRE C83035 Exeter St, Bourne, PE10 9XR

HIBALDSTOW MEDICAL PRACTICE C83033 11 Church Street, Hibaldstow, Brigg, DN20 9ED

HOLBEACH MEDICAL CENTRE C83028 Park Road, Holbeach, PE12 7EE

HORNCASTLE MEDICAL GROUP C83027 Spilsby Road, Horncastle, LN9 6AL

JAMES STREET FAMILY PRACTICE C83085 49 James Street, Louth, LN11 0JN

KIRTON MEDICAL CENTRE C83057 Boston Road, Kirton, PE20 1DS

LAKESIDE HEALTHCARE C83007 Wharf Rd, Stamford, PE9 2DH STAMFORD LINDUM MEDICAL PRACTICE C83009 1 Cabourne Court, Cabourne Avenue, Lincoln, LN2 2JP

LIQUORPOND SURGERY C83004 10 Liquorpond Street, Boston, PE21 8UE LITTLEBURY MEDICAL CENTRE C83065 Fishpond Ln, Holbeach, Spalding, PE12 7DE LONG SUTTON MEDICAL CTR. C83063 Trafalgar Square, Long Sutton, Spalding, PE12 9HB MARISCO MEDICAL PRACTICE C83064 Stanley Road, Mablethorpe, LN12 1DP

MARKET CROSS SURGERY C83649 Bourne Rd, Corby Glen, NG33 4BB

MARKET RASEN SURGERY C83043 Mill Road, Market Rasen, LN8 3BP

MARSH MEDICAL PRACTICE C83042 Keeling Street, North Somercotes, LN11 7QU MERTON LODGE SURGERY C83032 33 West Street, Alford, LN13 9HT

MILLVIEW MEDICAL CENTRE C83011 1 Sleaford Rd, Heckington, Sleaford, NG34 9QP MINSTER MEDICAL PRACTICE C83072 2 Cabourne Court, Cabourne Avenue, Lincoln, LN2 2JP

MOULTON MEDICAL CENTRE C83039 High St, Moulton, Spalding, PE12 6QB

MUNRO MEDICAL CENTRE C83022 West Elloe Ave, Spalding, PE11 2BY

NAVENBY CLIFF VILLAGES C83002 Grantham Road, Navenby, LN5 0JJ SURGERY NETTLEHAM MEDICAL PRACTICE C83031 14 Lodge Lane, Nettleham, Lincoln, LN2 2RS

NEWARK ROAD SURGERY C83071 501a Newark Road, Lincoln, LN6 8RT

NORTH THORESBY SURGERY C83061 Highfield Road, North Thoresby, DN36 5RT PARKSIDE MEDICAL CENTRE C83010 Tawney Street, Boston, PE21 6PF

PORTLAND MEDICAL PRACTICE C83001 60 Portland Street, Lincoln, LN5 7LB

RICHMOND MEDICAL CENTRE C83025 Moor Lane, North Hykeham, LN6 9AY

RUSKINGTON SURGERY C83013 6 Brookside Cl, Ruskington, Sleaford, NG34 9GQ SLEAFORD MEDICAL GROUP C83023 47 Boston Rd, Sleaford, NG34 7HD

SPILSBY SURGERY C83005 Bull Yard, Simpson Street, Spilsby, PE23 5LG ST. JOHNS MEDICAL CENTRE C83048 62 London Rd, Grantham, NG31 6HR

ST. PETERS HILL SURGERY C83040 15 St Peter's Hill, Grantham, NG31 6QA STACKYARD AND WOOLSTHORPE C83653 1 The Stackyard, Croxton Kerrial, SURGERY Grantham, NG32 1QS STICKNEY SURGERY C83055 Main Road, Stickney, PE22 8AA

SUTTERTON SURGERY C83614 Spalding Rd, Sutterton, Boston, PE20 2ET SWINESHEAD SURGERY C83015 Fairfax House, Packhorse Lane, Swineshead, PE20 3JE

SWINGBRIDGE SURGERY C83008 Swingbridge Rd, Grantham, NG31 7XT TASBURGH LODGE SURGERY C83634 30 Victoria Avenue, Woodhall Spa, LN10 6SQ THE BASSINGHAM SURGERY C83611 20 Torgate Lane, Bassingham, Lincoln, LN5 9HF

THE DEEPINGS PRACTICE C83026 Godsey Ln, Market Deeping, Peterborough, PE6 8DD THE GLEBE PRACTICE C83038 85 Sykes Lane, Saxilby, Lincoln, LN1 2NU

THE GLENSIDE COUNTRY C83024 St Johns Close, Grantham, NG33 4LY PRACTICE THE HARROWBY LANE SURGERY C83080 Harrowby Ln, Grantham, NG31 9NS

THE HEATH SURGERY C83046 London Road, Bracebridge Heath, Lincoln, LN4 2LA

THE INGHAM SURGERY C83052 Lincoln Road, Ingham, Lincoln, LN1 2XF

THE JOHNSON GP CENTRE C83631 Spalding Rd, Pinchbeck, Spalding, PE11 3DT THE NEW CONINGSBY SURGERY C83083 20 Silver Street, Coningsby, LN4 4SG

THE NEW SPRINGWELLS Y01652 Spring Wells, Billingborough, Sleaford, PRACTICE NG34 0QQ THE SIDINGS MEDICAL PRACTICE C83060 Sleaford Road, Boston, PE21 8EG

THE WELBY PRACTICE C82076 3 Swinehill, Harlaxton, Grantham, NG32 1HT THE WOODLAND MEDICAL C83041 Jasmin Road, Birchwood, Lincoln, LN6 PRACTICE 0QQ

THE WRAGBY SURGERY C83650 Old Grammar School Way, Wragby, Market Rasen LN8 5DA TRENT VALLEY SURGERY C83641 85 Sykes Lane, Saxilby, Lincoln, LN1 2NU

UNIVERSITY HEALTH CENTRE C83656 ULHS Ltd, 3 Campus Way, Lincoln, LN6 7GA VINE STREET SURGERY C83075 Vine St, Grantham, NG31 6RQ

WASHINGBOROUGH SURGERY C83058 School Lane, Washingborough, LN4 1BN

WELTON FAMILY HEALTH CENTRE C83037 4 Cliff Road, Welton, Lincoln, LN2 3JH

WILLINGHAM-BY-STOW SURGERY C83074 High Street, Willingham by Stow, Gainsborough, DN21 5JZ

WOODHALL SPA NEW SURGERY C83635 The Broadway, Woodhall Spa, LN10 6ST

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, remain accountable to the Membership.

3.2.2 The CCG will have the following four localities:

Lincolnshire East Lincolnshire West South West Lincolnshire South Lincolnshire

3.2.3. Each of the Localities will have its own Locality Clinical Chair, Chief Operating Officer, Chief Nurse and Finance Lead.

3.2 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.

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 Members’ rights are described further either in the Standing Orders which are detailed in Appendix 3 of this Constitution and include:  Calling and attending a general meeting of the Members.  Submitting a proposal for amendment of the Constitution.  Putting themselves forward for election to the Governing Body.  Removing the Chair (or other elected members) of the Governing Body.

3.4.2 The CCG will have six Clinical Members appointed to the Governing Body (the four Locality Clinical Leads, plus two GPs from anywhere across the county). The two independent GP’s must not be from the same locality.

3.4.3 The two GPs will be appointed following an application process, which will be supported by the Local Medical Committee.

3.5 Members’ Meetings

3.5.1 A Membership Forum, at which the member practice representatives will hold the Governing Body of the CCG to account, will meet at least four times a year. Meetings shall be facilitated by the CCG.

3.5.2 Representation at the Members Forum is based on one representative per 30,000 weighted population – which means eight representatives from the East Locality, eight from West Locality, five from South Locality and four from South West Locality, giving an overall membership of 25. Quoracy for the meetings is set out in the Standing Orders under 3.13.5.

3.6 Practice Representatives

3.6.1. Each Member practice has a nominated lead healthcare professional who represents the practice in the dealings with the CCG. This individual will be known as the Member practice representative.

3.6.2. Practice representatives of the Membership Forum represent their practice’s views and act on behalf of them, in matters relating to the CCG. The role of each Representative is to:

 Ensure the effective participation of each Member in the CCG, in order to develop and sustain high-quality commissioning arrangements and an understanding of local health needs;  Obtain and feedback the views of their member practice on matters relating to the CCG’s functions and duties;  Act and vote at all times in a way which represents the best overall interests of the patients of the CCG;  Feedback to the CCG the views of users, or potential users, of services in the area covered by the CCG, particularly in relation to any quality issues that might inform commissioning decisions;  Feed back to their practice any relevant information or guidance produced by the CCG, which may require changes in the way in which the practice functions, in respect of the provision of healthcare in the local area covered by the CCG, as well as facilitating the dissemination of newsletters or other updates to practice staff or attendees at their practices;  Establish effective working arrangements with the clinical leaders of the CCG’s main providers, to achieve improved local health outcomes;  Attend the regular Membership Forums and participate in the Annual Public Meeting; and  Ensure that key actions or information agreed by the CCG is noted and taken forward, as appropriate, by their own Member practice.

4 Arrangements for the Exercise of our Functions

4.1 Good Governance

4.1.2 The CCG will, at all times, observe generally accepted principles of good governance. These include but are not limited to:

a) Adoption of public governance to ensure best practice; b) Undertaking regular governance reviews; c) Adoption of standards and procedures that facilitate speaking out and the raising of concerns including a freedom to speak up guardian; d) Adopting CCG values that include standards of propriety in relation to the stewardship of public funds, impartiality, integrity and objectivity; e) The Good Governance Standard for Public Services; f) The standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’; g) The seven key principles of the NHS Constitution; h) Relevant legislation including such as the Equality Act 2010; and i) 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’.

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.

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) a 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; 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.

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 in the CCG handbook which is available on the following link website – to be inserted.

5.1.2 The CCG’s SoRD sets out:

 those decisions that are reserved for the membership as a whole;  those decisions that have been delegated by the CCG, the Governing Body or other 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, are accountable to the Members for the exercise of their delegated functions.

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 Governing Body members;  the procedures to be followed during meetings; and  the process to delegate powers.

5.2.2 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) (Delegated Financial Authority Limits)

5.3.1 The CCG has agreed a set of Standing Financial Instructions which include the delegated financial authority limits set out in the SoRD.

5.3.2 A copy of the Delegated Financial Authority Limits is included at Appendix 4 and form part of this Constitution.

5.4 The Governing Body: Its Role and Functions

5.4.1 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 (its main function); and for  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.

5.4.2 The CCG has also delegated the following additional functions to the Governing Body which are also set out in the SoRD. Any delegated functions must be exercised within the procedural framework established by the CCG and primarily set out in the Standing Orders and SFIs:

 Approving any functions of the CCG that are specified in regulations;  Ensuring delivery of the CCG’s statutory duties associated with its commissioning functions that have been delegated to the Governing Body as stated in section 5.9.6 below, including but not limited to; i. Assuring the quality of all commissioned services; ii. Safeguarding, and ensuring patient safety; iii. Promotion of a comprehensive health service and the mandate; iv. Delivery of statutory financial duties v. Meeting the public sector equality duty; vi. Working in partnership with the local authority(ies); vii. Promoting and securing the involvement of patients, carers, local people, clinicians, partners and other stakeholders; viii. Promoting awareness of the NHS Constitution; ix. Acting effectively, efficiently and economically; x. Securing continuous improvements in the quality of services, including primary medical services and specialised services, supporting the NHS Commissioning Board where required; xi. Reducing health inequalities; xii. Ensuring patient choice; xiii. Obtaining appropriate advice; xiv. Promoting innovation, research, education, training and integration; xv. Working with local partners to ensure the effective Emergency Planning and Resilience (EPRR)  Approving all other matters delegated to it by the CCG, as detailed within the Scheme of Reservation and Delegation. The Governing Body will delegate decision making to other committees to act on its behalf;  leading the development of vision and strategy of the CCG;  overseeing and monitoring quality improvement;  approving the CCG’s Commissioning Plans and its constitution arrangements;  stimulating innovation and modernisation;  overseeing and monitoring performance;

 overseeing risk assessment and securing assurance actions to mitigate identified strategic risks.  promoting a culture of strong engagement with patients, their carers, Members, the public and other stakeholders about the activity and progress of the CCG;  ensuring good governance and leading a culture of good governance throughout the CCG.  Any other matters not reserved to the membership.

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 in the CCG Handbook – to be inserted.

5.5.2 The National Health Service (Clinical Commissioning Groups) Regulations 2012 set out a minimum membership requirement of the Governing Body of:

 The Chair  The Accountable Officer  The Chief Finance Officer (Director of Finance and Contracting)  A Secondary Care Specialist  A Registered Nurse (who will be the same individual who fulfils the role of Director of Nursing for the CCG)  Two Lay Members  (one who has qualifications, expertise or experience to enable them to lead on finance and audit matters, 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:

 Four Locality Clinical Leads (one of whom will be known as the Clinical Leader)  Two GP members drawn from the member practices (not from the same Locality)  Three Lay Members

5.5.4 One of the appointed Lay Members shall be nominated as Deputy Chair of the Governing Body.

5.6 Additional Attendees at the Governing Body Meetings

5.6.1 The CCG Governing Body may invite other person(s) 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 CCG Governing Body will regularly invite the following individuals to attend any or all of its meetings as attendees:

 Public Health Representative  Healthwatch Representative  Four Chief Operating Officers

5.7 Appointments to the Governing Body

5.7.1 The process of appointing GPs to the Governing Body, the selection of the Chair, and the appointment procedures for other Governing Body Members is set out in the Standing Orders.

5.7.2 Also set out in the 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 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.

5.8.5 All members of the Remuneration Committee will be members of the CCG Governing Body.

5.8.6 The four Localities will have their own Executive Committee, established as a Committee of the Governing Body to oversee and manage locality/place based decisions as delegated by the Governing Body and to agree how Strategic Decisions are locally implemented to reflect local population health approach.

5.8.7 The CCG Locality Executive Committee Terms of Reference will set out the membership, remit, responsibilities and reporting arrangements of the Committee and be included in the CCG Governance Handbook

5.9 Committees of the Governing Body

5.9.1 The Governing Body will maintain the following statutory or mandated Committees:

5.9.2 Audit 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. 5.9.3 The Audit Committee will be chaired by a Lay Member who has qualifications, expertise or experience to enable them to lead on finance and audit matters and members of the Audit and Risk Committee may include people who are not Governing Body members.

5.9.4 Remuneration Committee: This Committee is accountable to the Governing Body and makes recommendations to the Governing Body about the remuneration, fees and other allowances (including pension schemes) for employees and other individuals who provide services to the CCG.

5.9.5 The Remuneration Committee will be chaired by a Lay Member other than the audit chair and only members of the Governing Body may be members of the Remuneration Committee.

5.9.6 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 is accountable 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 Vice Chair.

5.9.7 None of the above Committees may operate on a joint committee basis with another CCG(s).

5.9.8 The Terms of Reference for each of the above Committees are included in Appendix 2 to this Constitution and form part of the Constitution.

5.9.9 The Governing Body has also established a number of other Committees to assist it with the discharge of its functions. These Committees are set out in the SoRD and further information about these Committees, including terms of reference, are published in the CCG Handbook which is available on the website to be inserted.

5.10 Collaborative Commissioning Arrangements

5.10.1 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.

5.10.2 In addition to the formal joint working mechanisms envisaged below, the Governing Body may enter into strategic or other transformation discussions with its partner organisations, on behalf of the CCG.

5.10.3 The Governing Body must ensure that appropriate reporting and assurance mechanisms are developed as part of any partnership or other collaborative arrangements. This will include:  reporting arrangements to the Governing Body, at appropriate intervals;  engagement events or other review sessions to consider the aims, objectives, strategy and progress of the arrangements; and  progress reporting against identified objectives.

5.10.4 When delegated responsibilities are being discharged collaboratively, the collaborative arrangements, whether formal joint working or informal collaboration, must:  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;  specify how performance will be monitored and assurance provided to the Governing Body on the discharge of responsibilities, so as to enable the Governing Body to have appropriate oversight as to how system integration and strategic intentions are being implemented;  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;  specify under which of the CCG’s supporting policies the collaborative working arrangements will operate;  specify how the risks associated with the collaborative working arrangement will be managed and apportioned between the respective parties;  set out how contributions from the parties, including details around assets, employees and equipment to be used, will be agreed and managed;  identify how disputes will be resolved and the steps required to safely terminate the working arrangements;  specify how decisions are communicated to the collaborative partners.

5.11 Joint Commissioning Arrangements with Local Authority Partners

5.11.1 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. 5.11.2 Partnership working between the CCG and its Local Authority partners might 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 Governing Body the ability to enter into arrangements with one or more relevant Local Authority in respect of: (CCGs that have not delegated to their Governing Body should remove this sentence).

 Delegating specified commissioning functions to the Local Authority;  Exercising specified commissioning functions jointly with the Local Authority; 25

 Exercising any specified health -related functions on behalf of the Local Authority.

5.11.3 For purposes of the arrangements described in 5.11.2, the Governing Body may:

 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;  make the services of its employees or any other resources available to the Local Authority; and  receive the services of the employees or the resources from the Local Authority.  where the Governing Body makes an agreement with one or more Local Authority 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.

5.11.4 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.11.2 above.

5.11.5 (If joint working arrangements have been agreed with a combined authority, include the model wording here).

5.12 Joint Commissioning Arrangements – Other CCGs

5.12.1 The CCG may work together with other CCGs in the exercise of its Commissioning Functions.

5.12.2 The CCG delegates its powers and duties under 5.12 to the Governing Body and all references in this part to the CCG should be read as the Governing Body, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements.

5.12.3 The CCG may make arrangements with one or more other CCGs in respect of:  delegating any of the CCG’s commissioning functions to another CCG;  exercising any of the Commissioning Functions of another CCG; or  exercising jointly the Commissioning Functions of the CCG and another CCG.

5.12.4 For the purposes of the arrangements described at 5.12.3, the CCG may:

 make payments to another CCG;  receive payments from another CCG; or  make the services of its employees or any other resources available to another CCG; or  receive the services of the employees or the resources available to another CCG.

5.12.5 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. 5.12.6 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 5.12.3 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.

5.12.7 Where the CCG makes arrangements with another CCG as described at paragraph 5.12.3 above, the CCG shall develop and agree with that CCG an agreement setting 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 the parties, including details around assets, employees and equipment to be used under the joint working arrangements.

5.12.8 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.

5.12.9 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.

5.12.10 Only arrangements that are safe and in the interests of patients registered with Member practices will be approved by the Governing Body.

5.12.11 The Governing Body shall require, in all joint commissioning arrangements, that the lead Governing Body Member for the joint arrangements:

 make a quarterly written report to the Governing Body;  hold at least one annual engagement event to review the aims, objectives, strategy and progress of the joint commissioning arrangements; and

 publish an annual report on progress made against objectives.

5.12.12 Should a joint commissioning arrangement prove to be unsatisfactory the Governing Body 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.

5.13 Joint Commissioning Arrangements – Other CCGs

5.13.1 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.

5.13.2 The CCG delegates its powers and duties under 5.13 to the Governing Body and all references in this part to the CCG should be read as the Governing Body, except to the extent that they relate to the continuing liability of the CCG under any joint arrangements.

5.13.3 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.

5.13.4 The arrangements referred to in paragraph 5.13.3 above may include other CCGs, a combined authority or a local authority.

5.13.5 Where joint commissioning arrangements pursuant to 5.13.3 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.

5.13.6 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.

5.13.7 Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph 5.13.3 above, the CCG shall develop and agree with NHS England a framework setting 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, if applicable, payments towards a pooled fund and management of that fund;  contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.

5.13.8 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 5.13.

5.13.9 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.

5.13.10 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Governing Body.

5.13.11 The Governing Body of the CCG shall require, in all joint commissioning arrangements that the lead Governing Body Member for the joint arrangements make;

5.13.12 Should a joint commissioning arrangement prove to be unsatisfactory the Governing Body 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.

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 policy on conflicts of interest. 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 Standards of Business Conduct Policy.

6.1.4 The CCG has appointed the Audit Chair to be the Conflicts of Interest Guardian. In collaboration with the CCG’s governance lead, their role is to:

 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;  Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to conflicts of interest;  Support the rigorous application of conflict of interest principles and policies;  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  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.

6.2.2 The CCG will, as a minimum, publish the registers of conflicts of interest, gifts and hospitality of decision making staff and the procurement register of decisions and investments 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 reasonable 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.

6.2.7 Any declarations of interests, and arrangement agreed in any meeting of the Clinical Commissioning Group, Committees or Sub-Committees, or the Governing Body, the Governing Body’s Committees or Sub-Committees will be recorded in the minutes.

6.2.8 Where more than 50% of the members of a meeting are required to withdraw from a meeting or part of it, owing to the arrangements agreed for the management of conflicts of interest or potential conflicts of interest, the Chair (or deputy) will determine whether or not the discussion can proceed.

6.2.9 In making this decision the Chair will consider whether the meeting is quorate, in accordance with the number and balance of membership as set out in the CCG’s Standing Orders. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interest, the Chair of the meeting shall consult the Conflict of Interest Guardian on the action to be taken.

6.3 Training in Relation to Conflicts of Interest

6.3.1 The CCG ensures that relevant staff and all Governing Body members receive training on the identification and management of conflicts of interest and that relevant staff 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); 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 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 at To be inserted 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 Standards of Business Conduct policy.

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 of (AO) the 2006 Act, appointed by NHS England, with responsibility for ensuring the CCG: 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.

Area The geographical area that the CCG has responsibility for, as defined in part 2 of this constitution Chair of the CCG The individual appointed by the CCG to act as chair of the Governing Body Governing Body and who is usually either a GP member or a Lay Member of the Governing Body.

Chief Finance A qualified accountant employed by the CCG with Officer (CFO) responsibility for financial strategy, financial management and financial governance and who is a member of the Governing Body.

Clinical Commissioning A body corporate established by NHS England in Groups (CCG) accordance with Chapter A2 of Part 2 of the 2006 Act.

Committee A Committee created and appointed by the membership of the CCG or the Governing Body. Committees in If a Committee meets at the same time, in the same location, as Common another CCGs Committee, it is referred to legally as meeting as Committees in Common’. Such Committees in Common maintain a common agenda, but maintain their own attendance, minutes, action and decision logs allowing each Committee to retain transparent records of their own governance arrangements and outcomes.

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

Joint Committee Committees from two or more organisations that work together with delegated authority from both organisations to enable joint decision-making. This is different from Committees in Common.

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.

Locality Clinical Lead To be defined

Locality Chief To be defined. Operating Officer

Locality Chief Nurse To be defined.

Member/Member A provider of primary medical services to a registered patient list, practice who is a Member of the CCG.

Member practice Member practices appoint a healthcare professional to act as representative their practice representative in dealings between it and the 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 legislation refers to the NHS Commissioning Board and this is the legal name for NHS England. The NHS Commissioning Board has changed its operational name to ‘NHS England’.

Primary Care A Committee required by the terms of the delegation from NHS Commissioning England in relation to primary care commissioning functions. Committee The Primary Care Commissioning Committee reports to NHS England and the Governing Body

Professional An independent body accountable to the UK Parliament which Standards Authority 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.

Registers of Registers of the CCG 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 CCG;  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.

SFI Standing Financial Instructions, including Delegated Financial Authority Limits) (Appendix 4)

SO Standing Orders (Appendix 3)

SORD Scheme of Reservation and Delegation – held outside of the Constitution in the CCG Governance Handbook.

STP Sustainability and Transformation Partnerships – the framework within which the NHS and local authorities have 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”.

Sub-Committee A Committee created by and reporting to a Committee.

Appendix 2: Committee Terms of Reference

Audit Committee

Terms of Reference

1. GOVERNANCE NOTE

1.1. The Governing Body of Lincolnshire CCG (the “CCG”) has established a committee of the Governing Body to be known as the Audit Committee (the “Committee”). The Committee has no executive powers, other than those specifically delegated in these Terms of Reference.

2. CONSTITUTION

2.1. The Committee is established in accordance with the CCG’s constitution and Schedule 1A of the National Health Service Act 2006 (as amended) (the “NHS Act”). 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 constitution.

3. PURPOSE

3.1 The purpose of the Committee is to provide assurance to the Governing Body and CCG Member practices on the design, implementation and effectiveness of internal controls and to provide scrutiny over the discharge of the CCG’s statutory functions, including the delivery of financial duties.

4. ACCOUNTABILITY

4.1 The Committee is authorised by the Governing Body to execute any powers assigned to it by the Governing Body and those specifically delegated in these Terms of Reference and/or through the CCGs’ Scheme of Reservation and Delegation.

4.3 The 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 from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Governing Body to obtain outside legal or other independent professional advice and secure the attendance of external personnel with relevant experience and expertise if it considers this necessary. 5. ROLES AND RESPONSIBILITIES

5.1. The Committee will incorporate the following duties:

5.1.1. Integrated governance, risk management and internal control The 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 that support the achievement of the CCG’s objectives. Its work will dovetail with that of the Quality and Performance Committee which the CCG has established to seek assurance that robust clinical quality is in place.

In particular, the Committee will review the adequacy and effectiveness of:

 All risk and control related disclosure statements (in particular the governance statement), together with any appropriate independent assurances, prior to endorsement by the CCG;  The underlying assurance processes that indicate the degree of achievement of the CCG's 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; and  the policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud and Security Management Service.

In carrying out this work the Committee will agree an annual audit plan and primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these sources. It will also 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 Committee’s use of an effective assurance framework to guide its work and that of the audit and assurance functions that report to it.

5.1.2. Internal Audit

The Committee shall ensure that there is an effective internal audit function that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Committee, Accountable 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 CCG; • An annual review of the effectiveness of internal audit.

5.1.3. External Audit

The Committee shall review the work and findings of the External Auditors and consider the implications and responses by officers of the CCG 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 coordination, 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 CCG and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.

5.1.4. Other assurance functions

The Committee shall review the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the CCG. 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 and NHS Resolution) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).

5.1.5. Counter fraud

The Committee shall satisfy itself that the CCG has adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.

5.1.6. Management

The Committee shall request and review reports and positive assurances from directors and officers of the CCG on the overall arrangements for governance, risk management and internal control.

The Committee may also request specific reports from individual functions within the CCG as they may be appropriate to the overall arrangements.

5.1.7. Financial reporting

The Committee shall monitor the integrity of the financial statements of the CCG and any formal announcements relating to the CCG’s financial performance.

The 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 Committee shall review and approve the annual report and financial statements on behalf of the Governing Body and the CCG, focusing particularly on:

 The wording in the governance statement and other disclosures relevant to the terms of reference of the Committee;  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. 5.1.8. Whistleblowing

The Committee shall review the effectiveness of arrangements in place for allow staff 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.

5.1.9. Conflicts of Interest

The Committee shall receive reports in respect of any Conflicts of Interest breaches. The Committee shall review the impact and actions taken.

6. CHAIR ARRANGEMENTS

6.1. The CCG Governing Body shall appoint the Chair of the Committee from its Lay or Independent members. The Chair shall have the lead independent role in overseeing audit and remuneration in the CCG. In the event that the Chair is unavailable to attend, a member of the Committee will deputise and Chair the meeting.

7. MEMBERSHIP

7.1. Members of the Committee shall be appointed by the CCG Governing Body. Good practice recommends at least three Lay Members.

7.2. Membership will comprise:  Three Governing Body Lay Members

The Chair of the Governing Body, the Accountable Officer and the Chief Finance Officer shall not be members of the Audit Committee and will be invited to attend.

8. COMMITTEE CHAIR

The Lay Member on the Governing Body with a lead role in overseeing key elements of governance will Chair the Audit Committee.

In the event of the Chair of the Committee being unable to attend all or part of the meeting, he/she will nominate a replacement from within the Committee membership to deputise for that meeting.

9. ATTENDANCE AT MEETINGS

9.1. The Chief Finance Officer and appropriate Internal and External Audit representatives shall normally attend meetings but shall not have voting rights. In addition, the following good practice will be followed:

 At least once a year the Audit Committee should meet privately with the External and Internal Auditors;  Representatives from NHS Counter Fraud Authority may be invited to attend meetings and will normally attend at least one meeting each year;  Regardless of attendance, external audit, internal audit, local counter fraud and security management (NHS Counter Fraud Authority) providers will have full and unrestricted rights of access to the Committee;  The Accountable Officer will be invited to attend and discuss, at least annually with the Audit Committee, the process for assurance that supports the annual governance statement. He or she would also normally attend when the Audit Committee considers the draft internal audit plan and the annual accounts;  Any other officers of the CCG who have responsibility for specific areas (or similar) may be invited to attend, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that director; and

 The Chair of the Governing Body may also be invited to attend one meeting each year in order to form a view on, and understanding of, the Audit Committee’s operations.

10. QUORACY

10.1. The quorum necessary for the transaction of business shall be two Members.

11. DECISION MAKING AND VOTING

11.1. The Committee will use its best endeavours to make decisions by consensus. Exceptionally, where this is not possible the Chair (or Deputy) may call a vote.

11.2. Only members of the Committee set out in section 7 have voting rights. Each voting member is allowed one vote and a majority will be conclusive on any matter. Where there is a split vote, with no clear majority, the Chair of the Committee will hold the casting vote.

11.3 If a decision is needed which cannot wait for the next scheduled meeting or it is not considered necessary to call a full meeting, the Committee may choose to convene a telephone conference or conduct its business on a ‘virtual’ basis through the use of email communication. Minutes will be recorded for telephone conference and virtual meetings in accordance with relevant sections of the Lincolnshire CCG Governance Handbook.

12. REPORTING ARRANGEMENTS

12.1. The Committee shall report to the Governing Body on how it discharges its responsibilities. The minutes of the Committee’s meetings shall be formally recorded by the secretary and submitted to the Governing Body. The Chair of the Committee shall draw to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or that require executive action.

12.2. The Committee will report to the Governing Body at least annually on its work in support of the annual governance statement, specifically commenting on the:  Fitness for purpose of the assurance framework;  Completeness and ‘embeddedness’ of risk management in the organisation;  Integration of governance arrangements; Appropriateness of the evidence that shows the organisation is fulfilling regulatory requirements relating to its existence as a functioning business;  Robustness of the processes behind the quality accounts.

12.3. The annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee has considered in relation to the financial statements and how they were addressed.

13. FREQUENCY AND NOTICE OF MEETINGS 13.1. The Audit Committee must consider the frequency and timing of meetings needed to allow it to discharge all of its responsibilities. Meetings of the Committee shall be held at regular intervals, at such times and places that the CCG may determine, but not less than four times per year. The External Auditors or Head of Internal Audit may request a meeting if they consider that one is necessary. The Committee will agree an annual programme of meetings in advance to link with key business to be transacted. Papers will be issued at least five working days in advance of the meetings wherever possible.

13.2. The Chair of the Committee, Governing Body or Accountable Officer may call additional meetings as required, giving not less than 14 days’ notice.

14. SUB-COMMITTEES

14.1. Committee may delegate responsibility for specific aspects of its duties to sub committees or working groups. The Terms of Reference of each such sub- committee or working group shall be approved by the Committee and shall set out specific details of the areas of responsibility and authority.

14.2. Any sub-committees or working groups will report via their respective Chair’s following each meeting or at an appropriate frequency as determined by the Committee.

15. ADMINISTRATIVE SUPPORT

15.1. The CCG’s governance lead shall be secretary to the Committee and shall attend to provide appropriate support to the Chair and Audit Committee members. The secretary will be responsible for supporting the Chair in the management of the Audit Committee’s business and for drawing the Audit Committee’s attention to best practice, national guidance and other relevant documents, as appropriate. The secretary will either take minutes or make arrangements for minutes to be taken.

16. DECLARATIONS OF INTEREST, CONFLICTS AND POTENTIAL CONFLICTS 1 16.1. The provisions of Managing Conflicts of Interest: Statutory Guidance for CCGs or any successor document will apply at all times.

16.2. Where a member of the committee is aware of an interest, conflict or potential conflict of interest in relation to the scheduled or likely business of the meeting, they will bring this to the attention of the Chair of the meeting as soon as possible, and before the meeting where possible.

16.3. The Chair of the meeting will determine how this should be managed and inform the member of their decision. The Chair may require the individual to withdraw from the meeting or part of it. Where the Chair is aware that they themselves have such an interest, conflict or potential conflict of interests they will bring it to the attention of the Committee, and the Deputy Chair will act as Chair for the relevant part of the meeting.

16.4. Any declarations of interests, conflicts and potential conflicts, and arrangements to manage those agreed in any meeting of the Committee, will be recorded in the minutes.

16.5. Failure to disclose an interest, whether intentional or otherwise, will be treated in line with the Managing Conflicts of Interest: Revised Statutory Guidance and may result in suspension from the Committee.

16.6. All members of the Committee shall comply with, and are bound by, the requirements in the Lincolnshire CCG’s Constitution, Standards of Business Conduct and Conflicts of Interest Policy, the Standards of Business Conduct for NHS staff (where applicable) and NHS Code of Conduct.

17. REVIEW OF TERMS OF REFERENCE

17.1. These terms of reference and the effectiveness of the Committee will be reviewed at least annually or sooner if required. The Committee will recommend any changes to the terms of reference to the Governing Body and will be approved by the Governing Body.

Reviewed by Audit Committee: [Date]

Approved by Governing Body: (Date)

(Review period as set out in the Review Log included in the CCG Corporate Governance Handbook)

Remuneration Committee

Terms of Reference

1. GOVERNANCE NOTE

The Governing Body of Lincolnshire CCG has established a Committee of the Governing Body to be known as the Remuneration Committee (the “Committee”). In accordance with section 14M and 14L(3) of the NHS Act. The Committee has no executive powers, other than those specifically delegated in these Terms of Reference.

2. CONSTITUTION

2.1. The Committee is established in accordance with the CCG’s Constitution and Schedule 1A of the National Health Service Act 2006 (as amended) (the “NHS Act”). 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 constitution.

2.2 Subject to any restrictions set out in the relevant legislation, the Remuneration Committee has the function of making recommendations to the Governing Body about the exercise of its functions under section 14L(3)(a) and (b), i.e. its functions in relation to:

a) determining the remuneration, fees and allowances payable to employees of the CCG and to other persons providing services to it; and b) determining allowances payable under pension schemes established by the CCG.

3. PURPOSE 3.1 The purpose of the Committee is to make recommendations to Governing Body on the appropriate remuneration and terms of service for the Accountable Officer, Directors, other Very Senior Managers, Clinicians and Lay Members. The Committee will have delegated powers to act on behalf of the CCG within the approved Terms of Reference.

3.2 The Committee shall adhere to all relevant laws, regulations and policies in all respects including (but not limited to) determining levels of remuneration that are sufficient to attract, retain and motivate executive directors and senior staff whilst remaining cost effective.

4. ACCOUNTABILITY

4.1 The Remuneration Committee is authorised by the CCG Governing Body to commission any reports, surveys, legal or other independent professional advice it deems necessary to assist in fulfilling its obligations.

4.2 The Committee may investigate, monitor and review activity within its Terms of Reference. It is authorised to seek any information it requires from any Committee, group, clinician or employee (including interim and temporary members of staff), contractor, sub-contractor or agent, who are directed to co-operate with any request made by it.

4.4 The Committee will apply best practice in the decision making process. For example, when considering individual remuneration the Committee will:

a) Comply with current disclosure requirements for remuneration; b) On occasion, and where appropriate, seek independent advice about remuneration for individuals; and c) Ensure that decisions are based on clear and transparent criteria and be able to withstand public scrutiny and audit.

4.5 For the avoidance of doubt, in the event of any conflict the Standing Orders, the Standing Financial Instructions and the Scheme of Reservation and Delegation of the CCG will prevail over these Terms of Reference.

5. ROLES AND RESPONSIBILITIES

5.1. The Committee will incorporate the following duties:

5.1.1. With regard to the Accountable Officer, Directors and other Very Senior Managers, make recommendations to Governing Body all aspects of salary (including any performance-related elements, bonuses); 5.1.2. Make recommendations to Governing Body contractual arrangements for clinicians engaged to support the CCG Governing Body;

5.1.3. Make recommendations on provisions for other benefits, including pensions and cars for all staff;

5.1.4. Make recommendations for arrangements for termination of employment and other contractual terms for all staff (decisions requiring dismissal shall be referred to the Governing Body);

5.1.5. Ensure that officers are fairly rewarded for their individual contribution to the organisation – having proper regard to the organisation’s circumstances and performance and to the provisions of any national arrangements for such staff;

5.1.6. Ensure proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate, advising on and overseeing appropriate contractual arrangements for such staff. This will apply to all CCG staff;

5.1.7. Ensure proper calculation and scrutiny of any special payments.

6. MEMBERSHIP

6.1. Members of the Committee must be appointed from the CCG Governing Body.

6.2. To maintain the independence of members, the Committee will comprise of three Lay members (this will not include the Audit Committee Chair)

6.3. Only members of the Committee have the right to attend meetings, however, individuals such as the Accountable Officer, Chief Finance Officer, HR Advisor and external advisors may be invited to attend for all or part of a meeting as and when appropriate but shall not have voting rights. No member or attendee shall be party to discussions about their own remuneration or terms of service.

7. COMMITTEE CHAIR

7.1. The CCG Governing Body shall appoint the Chair of the Committee, who will be one the Lay Members. In the event that the Chair is unavailable to attend, one of the other Lay Members will deputise and Chair the meeting.

8. QUORACY

8.1 The quorum necessary for the transaction of business shall be three Lay Members.

8.2 A duly convened meeting of the Committee at which quorum is present at the meeting, or are contactable by telephone conference call, is competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

9. DECISION MAKING AND VOTING

9.1. The Committee will use its best endeavours to make decisions by consensus. Exceptionally, where this is not possible the Chair (or Deputy) may call a vote.

9.2. Only members of the Committee set out in section 6 have voting rights. Each voting member is allowed one vote and a majority will be conclusive on any matter. Where there is a split vote, with no clear majority, the Chair of the Committee will hold the casting vote.

9.3. If a decision is needed which cannot wait for the next scheduled meeting or it is not considered necessary to call a full meeting, the Committee may choose to convene a telephone conference or conduct its business on a ‘virtual’ basis through the use of email communication. Minutes will be recorded for telephone conference and virtual meetings in accordance with relevant sections of the Lincolnshire CCG Governance Handbook.

10. REPORTING ARRANGEMENTS

10.1. The Committee shall formally report to the Governing Body on its proceedings after each meeting on all matters within its duties and responsibilities. The report shall be presented to the confidential meeting of the Governing Body.

10.2. The Remuneration Committee shall make recommendations to the Governing Body on any area within its remit where action is improvement is needed.

11. FREQUENCY AND NOTICE OF MEETINGS

11.1. Meetings will be held at when required but at least once a year.

12. ADMINISTRATIVE SUPPORT

12.1. The CCG’s governance lead shall be secretary to the Committee and shall attend to provide appropriate support to the Chair and Remuneration Committee members. The secretary will be responsible for supporting the Chair in the management of the Committee’s business and for drawing the Remuneration Committee’s attention to best practice, national guidance and other relevant documents, as appropriate. The secretary will either take minutes or make arrangements for minutes to be taken.

13. DECLARATIONS OF INTEREST, CONFLICTS AND POTENTIAL CONFLICTS

13.1. The provisions of Managing Conflicts of Interest: Statutory Guidance for CCGs or any successor document will apply at all times.

13.2. Where a member of the committee is aware of an interest, conflict or potential conflict of interest in relation to the scheduled or likely business of the meeting, they will bring this to the attention of the Chair of the meeting as soon as possible, and before the meeting where possible.

13.3. The Chair of the meeting will determine how this should be managed and inform the member of their decision. The Chair may require the individual to withdraw from the meeting or part of it. Where the Chair is aware that they themselves have such an interest, conflict or potential conflict of interests they will bring it to the attention of the Committee, and the Deputy Chair will act as Chair for the relevant part of the meeting.

13.4. Any declarations of interests, conflicts and potential conflicts, and arrangements to manage those agreed in any meeting of the Committee, will be recorded in the minutes.

13.5. Failure to disclose an interest, whether intentional or otherwise, will be treated in line with the Managing Conflicts of Interest: Revised Statutory Guidance and may result in suspension from the Committee.

13.6. All members of the Committee shall comply with, and are bound by, the requirements in the Lincolnshire CCG’s Constitution, Standards for Business Conduct and Conflicts of Interest Policy, the Standards of Business Conduct for NHS staff (where applicable) and NHS Code of Conduct.

14. REVIEW OF TERMS OF REFERENCE

14.1. These terms of reference and the effectiveness of the Committee will be reviewed at least annually or sooner if required. The Committee will recommend any changes to the terms of reference to the Governing Body and will be approved by the Governing Body.

Reviewed by Remuneration Committee: [Date] Approved by Governing Body: (Review period as set out in the Review Log included in the CCG Corporate Governance Handbook)

Primary Care Commissioning Committee

Terms of Reference

1. INTRODUCTION

1.1 In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended); NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference to NHS Lincolnshire CCG. Schedule 1 and 2 are specified in the NHS Lincolnshire CCG Delegated Agreement.

1.2 The CCG has established the Primary Care Commissioning Committee. The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

1.3 It is a Committee comprising representatives of the following organisations:  NHS Lincolnshire CCG  Healthwatch  Lincolnshire Council Council (Health and Wellbeing Representative)

2. STATUTORY FRAMEWORK

2.1. NHS England has delegated to NHS Lincolnshire CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the National Health Service Act 2006 (as amended).

2.2. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.

2.3. Arrangements made under section 13Z do not affect the liability of NHS England 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).

2.4. 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).

2.5. The Committee is established as a committee of the Governing Body in accordance with Schedule 1A of the National Health Service Act 2006 (NHS Act).

2.6. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

3. ROLE OF THE COMMITTEE

3.1. 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 CCG, under delegated authority from NHS England.

3.2. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and NHS Lincolnshire CCG, which will sit alongside the delegation and Terms of Reference.

3.3. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

3.4. 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.

3.4.1. This includes the following:

 Decisions in relation to the commissioning, procurement and management of GMS, PMS and APMS contracts, including but not limited to the following activities:  Designing PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing breach/remedial notices, and removing a contract  Newly designed enhanced services (‘Local Enhanced Services’ and Direct Enhanced Services’);  Design of local incentive schemes as an alternative to the Ouality Outcomes Framework  Decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices;  Decisions about ‘discretionary’ payments;  Decisions about commissioning urgent care (including home visits as required) for out of area registered patients;  The approval of practice mergers;  Planning primary medical care services in the Area, including carrying out needs assessments;  Undertaking reviews of primary medical care services in the Area;  Decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list);  management of the Delegated Funds in the Area;  Decisions in relation to Premises Costs Directions Functions;  Co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and

 Such other ancillary activities that are necessary in order to exercise the Delegated Functions.

3.5. The CCG will also carry out the following activities:

a) To plan, including needs assessment, primary medical care services in the CCG’s geographical area; b) To undertake reviews of primary medical care services in the CCG’s geographical area; c) To co-ordinate a common approach to the commissioning of primary care services generally; d) To manage the budget for commissioning of primary medical care services in the CCG’s geographical area

4. GEOGRAPHICAL COVERAGE

4.1. The Committee will comprise NHS Lincolnshire CCG’s geographical area.

5. MEMBERSHIP

5.1. The membership of the Committee is as follows:

 Three/Four Governing Body Lay Members  Accountable Officer or nominated Deputy  Chief Finance Officer or nominated Deputy  CCG Registered Nurse (Executive Nurse) or nominated Deputy  CCG Secondary Care Doctor  GP Member

Representatives shall attend the Committee as regular attendees as follows:

 NHS England Primary Care Representative  Clinical Representatives from the four Localities  Health and Wellbeing Board  Senior Healthwatch Representatives

5.2. Officers of the CCG shall attend or nominate deputies appropriate to the items for discussion on the agenda. The Committee may also request attendance by appropriate individuals to present relevant reports and/ or advise the Committee.

5.3. The Chair of the Committee shall be the Governing Body Primary Care Commissioning Lay Member.

5.4. The Deputy Chair of the Committee shall be one of the Lay Members (but not the Audit Committee Chair)

5.5 GP members of the Governing Body shall be invited to attend meetings to participate in strategic discussions on primary care issues, subject to adherence with the CCG’s conflicts of interest requirements and the appropriate management of conflicts of interest. They will be required, for example, to withdraw from the meeting during the deliberations leading up to decisions and from the decision where there is an actual or potential conflict of interest.

6. MEETINGS AND VOTING

6.1. The Committee will operate in accordance with the CCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of the meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 working 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.

6.2. Each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible.

6.3. If a decision is needed which cannot wait for the next scheduled meeting or it is not considered necessary to call a full meeting, the Committee may choose to convene a telephone conference or conduct its business on a ‘virtual’ basis through the use of email communication. Minutes will be recorded for telephone conference and virtual meetings in accordance with the Lincolnshire Corporate Governance Framework.

6.4. Members are required to declare any interest relating to any matter to be considered at each meeting, in accordance with the CCG’s constitution and the CCG Standards for Business Conduct and Managing Conflicts of Interest Policy. Members who have declared an interest will be required to leave the meeting at the point at which a decision on such matter is being made. At the discretion of the Chair, they may be allowed to participate in the preceding discussion.

7. QUORUM 7.1. A quorum shall be four voting members, at least two of whom shall be Lay Members, to include the Chair or Deputy Chair. Deputies are invited to attend in the place of the regular members as required.

7.2. A duly convened meeting of the Committee at which quorum is present at the meeting, or are contactable by telephone conference call, is competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

7.3 If a decision is needed which cannot wait for the next scheduled meeting or it is not considered necessary to call a full meeting, the Committee may choose to convene a telephone conference or conduct its business on a ‘virtual’ basis through the use of email communication. Minutes will be recorded for telephone conference and virtual meetings in accordance with relevant sections of the Lincolnshire CCG Governance Handbook

8. FREQUENCY AND NOTICE OF MEETINGS

8.1. The meetings held in public session will take place quarterly. The meetings to discuss items of a confidential nature will be held monthly and cancelled if necessary. On the dates of the meetings held in public session the meetings will be divided into two sections; Public and Confidential. The Public session will commence at the start of the meeting.

8.2. Meetings of the Committee: a) Shall be held in public; b) 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.

8.3. 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.

8.4. The Committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

8.5. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

8.6. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Standing Orders.

8.7. The Committee will present its minutes to NHS England Midlands and the Governing Body of the CCG each quarter for information.

8.8. The CCG will also comply with any reporting requirements set out in its constitution.

8.9. It is envisaged that these Terms of Reference will be reviewed from time to time, reflecting experience of the Committee in fulfilling its functions. NHS England may also issue revised model terms of reference from time to time.

9. ACCOUNTABILITY OF THE COMMITTEE

9.1. The Primary Care Commissioning Committee is a Committee of the Governing Body and is accountable for making new decisions on review, planning and procurement of primary care services in Lincolnshire, under delegated authority to the CCG from NHS England.

For the avoidance of doubt, in the event of any conflict between the terms of Delegation and Terms of Reference and the Standing Orders or Prime Financial Policies of any of the members, the Delegation will prevail.

10. PROCUREMENT OF AGREED SERVICES

10.1. The detailed arrangements regarding procurement are set out in the delegation agreement.

11. DECISIONS

11.1. The Committee will make decisions within the bounds of its remit.

11.2. The decisions of the Committee shall be binding on NHS England and Lincolnshire CCG.

11.3 The Committee will produce an executive summary report which will be presented to the NHS England Midlands and the Governing Body of the CCG each month for information.

12. REVIEW OF TERMS OF REFERENCE

12.1. These Terms of Reference and the effectiveness of the Committee will be reviewed at least annually or sooner if required. The Committee will recommend any changes to the Terms of Reference to the Governing Body and will be approved by the Governing Body and NHS England.

Reviewed by Remuneration Committee: [Date] Approved by Governing Body:

(Review period as set out in the Review Log included in the CCG Corporate Governance Handbook)

Appendix 3: Standing Orders

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 Lincolnshire Clinical Commissioning Group so that group can fulfil its obligations, as set out largely in the NHS Act 2006, as amended by the 2012 Act and related regulations. They are effective from the 1 April 2020.

1.1.2. The standing orders, together with the CCG’s scheme of reservation and delegation and the CCG’s standing financial instructions, 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 appointment of member practice representatives and other members of the Governing Body 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 process for identifying, declaring and managing conflicts of interests and f) the standards of conduct.

1.1.3 These arrangements must comply, and be consistent where applicable, with requirements set out in the NHS Act 2006 (as amended by the 2012 Act) and related regulations and take account as appropriate of any relevant guidance.

1.1.4 The Standing orders, and Standing Financial Instructions (Delegated Financial Authority Limits) are appended to and have effect as if incorporated into the CCG’s constitution. CCG members, members of the Governing Body, members of the Governing Body’s committee and sub-committees, members of the CCG’s committees and sub-committees, employees and persons working on behalf of the CCG should be aware of the existence of these documents and, where necessary, be familiar with their detailed provisions. Failure to comply with the standing orders, Standing Financial Instructions (Delegated Financial Authority Limits) may be regarded as a disciplinary matter that could result in dismissal.

1.1.5 These Standing Orders apply to the Members’ Forum and any committees of the Governing Body unless it is stated they do not.

1.1.6 These Standing Orders apply to the Governing Body and any committees of the Governing Body unless it is stated they do not.

1.2. Schedule of matters reserved to the Clinical Commissioning Group and the scheme of reservation and delegation

1.2.1. The NHS Act 2006 (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.

1.2.2. The CCG has decided that certain decisions may only be exercised by the CCG in formal session. Members will transact matters reserved to the membership at meetings of the members known as the Members’ Forum. These decisions and also those delegated are contained in the CCG’s scheme of reservation and delegation (Please see CCG Governance Handbook).

1.2.3. All other matters are delegated to the Governing Body. Full details relating to the matters reserved and delegated are to be found in the CCG’s scheme of reservation and delegation (Please see CCG Governance Handbook).

2. THE CLINICAL COMMISSIONING GROUP: COMPOSITION OF MEMBERSHIP, KEY ROLES AND APPOINTMENT PROCESS

2.1. Composition of Membership

2.1.1. The CCG is a membership body comprised of GP practices in the Lincolnshire area. Full details of the area covered and a list of member practices is set out in section 3 of the CCG’s Constitution The nature of the membership and relationship with the CCG are set out in the Constitution section 3.

2.1.2. Full meetings of the membership are to be known as ‘The Members’ Forum’.

2.1.3. Members are represented by the 25 individuals on the Members Forum. As set out in Section 3.5.2 of the Constitution the Members Forum is based on one representative per 30,000 weighted population – which means eight representatives from the East Locality, eight from West Locality, five from South Locality and four from South West Locality, giving an overall membership of 25. The representatives must be a healthcare professional as defined in the legislation.

2.1.4 Section 5 of the CCG’s Constitution provides details of the governing structure used in the CCG’s decision-making processes, whilst section 5.5 of the Constitution outlines certain key roles and responsibilities within the CCG and its Governing Body, including the role of practice representatives (section 3.6 of the Constitution).

2.2. Key Roles

2.2.1. Section 5.5 of the CCG’s Constitution sets out the composition of the CCG’s Governing Body and how it will be appointed. Whilst the CCG Governance Handbook identifies certain key roles and responsibilities within the CCG and its Governing Body. These standing orders set out how the CCG appoints individuals to these key roles.

All Governing Body individuals are to be appointed in accordance with the principles of ‘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

2.2.2. The Chair of the Governing Body, is subject to the following appointment process: a) Eligibility and exclusion– Must meet the core competencies identified for the role of Chair Individuals will not be appointed unless they meet the requirements of the descriptions (including the exclusion criteria) as set out in the CCG Regulations 2012. b) Appointment process – Interview against person specification and job description for the role which are in line with the NHS England guidance entitled Clinical Commissioning Group Governing Body members; Role Outlines, attributes and skills;

c) Term of office – Initially for three years. d) Eligibility for reappointment – Maximum two consecutive terms in office (subject to satisfactory appraisal and no objections have been received from the Members’ Forum). e) Grounds for removal from office - See section 2.2.12 f) Notice period – See section 2.2.13

2.2.3. The Accountable Officer, is subject to the following appointment process: a) Nominations – n/a b) Eligibility – Appointment to be from individuals who meet the core competencies identified for the Accountable Officer role. Appointment to be proposed by the CCG and appointed to by NHS England. c) Appointment process – Advert, assessment process and interview. d) Term of office – substantive appointment e) Eligibility for reappointment – Not applicable f) Grounds for removal from office - See section 2.2.12 g) Notice period – See section 2.2.13

2.2.4. The Chief Finance Officer is subject to the following appointment process: a) Nominations – n/a b) Eligibility – Initial appointment from a pool of people that have passed National Assessment Centre to assess capability to meet the core competencies identified for the CFO role. Subsequent appointments to be via open advert. c) Appointment process – Advert, assessment process and interview. d) Term of office – substantive appointment e) Eligibility for reappointment – Not applicable. f) Grounds for removal from office - See section 2.2.12 g) Notice period – See section 2.2.13

2.2.6 The Four Locality Clinical Leads (GP Members on the Governing Body) are subject to the following appointment/election process:

a) Nominations – Nomination by individual Member practice; b) Eligibility – An individual appointed by a practice (who is a Member of NHS Lincolnshire CCG) to act on its behalf in the dealings between it and the Group, under regulations made under section 89 or 94 of the 2006 Act (as amended by section 28 of the 2012 Act) or directions under section 98A of the 2006 Act (as inserted by section 49 of the 2012 Act). c) Exclusion criteria – An individual who has a major conflict of interest (such as the Clinical Directors of the Primary Care Networks) may not be appointed. An individual is excluded if they do not meet the requirements set out in the CCG Regulations 2012 d) Appointment process – Election through each individual Local Executive Committee/Forum. e) Term of office – Initially for three years (subject to satisfactory appraisal by the CCG Chair and no objections have been received from the Members’ Forum). f) Eligibility for reappointment – Maximum two consecutive terms in office g) Grounds for removal from office - See section 2.2.12 h) Notice period – See section 2.2.13

2.2.7 The Five Lay Members are subject to the following appointment process: a) Nominations – n/a b) Eligibility and exclusion– Interview against person specification and job description for the role which are in line with NHS England guidance entitled Clinical Commissioning Group Governing Body members; Role Outlines, attributes and skills;

Individuals will not be appointed unless they meet the requirements of the descriptions (including the exclusion criteria) set out in the CCG Regulations 2012. c) Appointment process – Advert and interview d) Term of office – Three years (annually reviewable). e) Eligibility for reappointment – maximum two consecutive terms in office (subject to satisfactory appraisal by the CCG Chair and no objections have been received from the Members’ Forum). f) Grounds for removal from office - See section 2.2.12 g) Notice period – Eligible to resign with immediate effect as not a CCG employee.

2.2.8 The Chief Nurse is subject to the following appointment process: a) Nominations – n/a b) Eligibility –Professional Registration. No conflicts of interest as defined by national guidance on NHS England website. Appraisal at interview against person specification and job description for the role. c) Appointment process – Advert and interview d) Term of office – substantive post e) Eligibility for reappointment – n/a f) Grounds for removal from office - See section 2.2.12 g) Notice period – See section 2.2.13

2.2.9 The Secondary Care Doctor is subject to the following appointment process: a) Nominations – Not applicable b) Eligibility –As defined in the CCG Regulations 2012. Individuals will not be appointed unless they meet the requirements of the description c) Appointment process – Advert and interview.

d) Term of office – Three years (annually reviewable). If the term of office is not to be continued at annual review, the Accountable Officer is able to serve three months’ notice. e) Eligibility for reappointment – maximum two consecutive terms in office (subject to satisfactory appraisal by the CCG Chair and no objections have been received from the Members’ Forum). f) Grounds for removal from office - See section 2.2.12 g) Notice period – see section 2.2.13

2.2.10 Two GP Representatives will be drawn from the CCG membership and subject to the following appointment process: a) Expressions of Interest – Individuals will complete an application process which will include setting out their key characteristics against a published specification. b) Eligibility – GP member of NHS Lincolnshire CCG. c) Appointment process – Advert and interview. d) Term of office – Initially for three years (annually reviewable). If the term of office is not to be continued at annual review, the Accountable Officer is able to serve three months’ notice. e) Eligibility for reappointment – Maximum two consecutive terms in office (subject to satisfactory appraisal by the CCG Chair and no objections have been received from the Members’ Forum). f) Grounds for removal from office: See section 2.2.12 g) Notice period: See section 2.2.13

2.2.11 Deputy Chair

The Deputy Chair will be selected from the five Lay Members by the Governing Body members and will fulfil the specific requirements set out in the CCG Regulations 2012.

2.2.12 Removal from office

 If they fail to attend a minimum of 75% of the meetings to which they are invited.  If they are deemed to have not met the expected standards of performance at their annual appraisal.  If they no longer fulfil the requirements of their role or become ineligible for the role as set out in the CCG regulations (2012) Schedules 4 and 5.  If they have behaved in a manner or exhibited conduct which has or is likely to be detrimental to the honour and interest of the Governing Body or the CCG and is likely to bring the Governing Body or the CCG into disrepute. This includes but is not limited to dishonesty, misrepresentation (either knowingly or fraudently); defamation of any member of the Governing Body (being slander or libel); abuse of position, non- declaration of a known conflict of interest; seeking to manipulate a decision of the Governing Body in a manner that would ultimately be in favour of that member whether financially or otherwise.  Are subject to disciplinary proceedings by a regulator or professional body.

 Members will be suspended pending the outcome of an investigation if they are suspended or under investigation by a regulator or professional body.

2.2.13 Notice period

 Officers notice period if defined in their contract of employment.

 For all other members, a three month notice period is required to be given in writing to the Chair (with exception of the Lay Members who are not employees and therefore eligible to resign with immediate effect).

3. MEETINGS AND DECISION MAKING

Governing Body

3.1 Calling meetings

3.1.1 The Governing Body of the CCG will meet at least eight times per year and the meetings will be held in public.

3.1.2 The agenda will be agreed between the CCG’s Chair and Accountable Officer.

3.1.3 The agenda and supporting papers will be sent to all members five working days before the meeting and either manually or electronically, whichever is appropriate at the time.

3.1.4 The Chair may call a meeting at any time.

3.1.5 One third of more or more Members of the Governing Body may requisition a meeting in writing. If the Chair refuses, or fails, to call a meeting within seven working days of a requisition being presented, the Members signing the Requisition may forthwith call a meeting.

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 six 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 six working days before the meeting takes place.

The agenda and supporting papers will be circulated to all members of a meeting five working days before the date the meeting will take place.

3.2.2 Agendas and certain papers for the CCG’s Governing Body – including details about meeting dates, times and venues - will be published on the CCG’s website at to be inserted.

3.3 Petitions

3.3.1 Where a petition has been received by the CCG, the Chair of the Governing Body shall receive the petition at the start of the meeting in public session.

3.4 Chair of a meeting

3.4.1 At any meeting of the CCG or its Governing Body or of a committee the Chair of the CCG, 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.

3.5 Chair's ruling

3.5.1 The decision of the CCG Chair on questions of order, relevancy and regularity and their interpretation of the Constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.

3.6 Quorum

The quorum will be 50% of the members of the Governing Body which must include:

 At least three healthcare professionals, at least one of whom is a GP; and  At least two Lay Members, and  Either the Chief Finance Officer or the Accountable Officer; and  Either the Chair or Deputy Chair.

3.6.1 The same quorum will apply to any decision requiring a Governing Body vote that is held outside of the meeting. 3.6.2 3.6.3 A Governing Body Member may nominate a deputy to attend on their behalfWhich will be subject to agreement of the Chair in advance of the meeting.Where a nominated deputy attends, the nominated individual will have delegated responsibility for representation at meetings including voting, actions as required and any decisions made.

3.6.4 For all other of the CCG’s committees and sub-committees, including the Governing Body’s committees, the details of the quorum for these meetings and status of representatives are set out in the appropriate Terms of Reference.

3.6.5 In exceptional circumstances and where agreed by the Chair, Members of the CCG Governing Body may participate in the meeting by telephone, by the use of telephone conferencing facilities where available. Participation in a meeting in this manner shall be deemed to constitute presence in person at the meeting.

3.7 Decision making

3.7.1 Section 5 of the CCG’s Constitution, together with the scheme of reservation and delegation, sets out the governing structure for the exercise of the CCG’s statutory functions. Generally it is expected that at the CCG’s / Governing Body’s meetings 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: 3.7.1.1 Eligibility – Governing Body Members 3.7.1.2 Majority necessary to confirm a decision – Majority of votes cast 3.7.1.3 Voting arrangements – determined by a show of hands of those present in the room or via ballet using electronic means subject to the agreement of the Chair. 3.7.1.4 Casting vote – The Chair (in the case of an equal number of votes being cast).

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.

3.7.3 For all other of the CCG’s committees and sub-committees, including the Governing Body’s committees and sub-committee, the details of the process for holding a vote are set out in the appropriate Terms of Reference which includes the Audit Committee, Remuneration Committee and Primary Care Commissioning Committee (as appended to the Constitution).

3.7.4 All other Committee Terms of Reference are included in the Corporate Governance Handbook.

3.8 Emergency powers and urgent decisions

3.8.1 Emergency meetings of the Governing Body, Audit Committee, or Remuneration Committee and any other committees can be called at the request of the respective chair of the meetings, the Accountable Officer, the Chief Finance Officer or Lay Member, Governance with the responsibility for governance.

3.8.2 The need for an urgent decision exceeding individual’s delegated authority can be agreed by the Accountable Officer or Deputy (Chief Finance Officer or Chief Nurse) and the Chair. Such decisions must be reported to the next Governing Body Meeting. In such cases where the CCG is responding to an Emergency Planning Resilience and Response (EPRR) issue or when there is a need to implement the Business Continuity Plan then the Senior Officer with responsibility for decision making at the time will have the authority to make emergency decisions. Any decisions made must be reported upon as soon as possible following any incident to the Accountable Officer or Chief Finance Officer and the Chair and must be reported to the next Governing Body Meeting.

3.8.3 Where an urgent decision or approval needs to be made before the next scheduled meeting of the Governing Body a “virtual” decision can be made by contacting all voting members, usually by electronic means, including all the relevant information for them to make an informed decision. There must be a majority response to the proposals which must be quorate in line with the Terms of Reference. Any decision must be reported to the next meeting of the Governing Body.

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 the majority of group members 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 Governing Body’s Audit 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 of the meeting present at the meeting shall be recorded in the minutes of the CCG’s meetings. The names of all members of the Governing Body present shall be recorded in the minutes of the Governing Body meetings. The names of all members of the Governing Body’s committees present shall be recorded in the minutes of the respective Governing Body committee meetings.

3.11 Minutes

3.11.1 The CCG must keep minutes of all formal meetings of the CCG Governing Body and meetings of any Committee or Sub-Committee of the CCG Governing Body carrying out powers of functions of the CCG, including:

 The names of the persons and their role present at the meeting;  The decisions made at the meetings and where appropriate the reasons for the decisions;  The name of the person responsible for taking the minutes; and  Recording any declarations of interest and making these visible in line with NHS England’s Managing Conflict of Interest; revised statutory guidance for CCGs 2017.

3.11.2 The minutes of the Governing Body, Governing Body’s committee meetings will be formally signed off by the respective Governing Body, Governing Body’s Committee or Sub-Committee at their next meeting.

3.11.3 Any public minutes shall be published on the CCG’s website.

3.11.4 Minutes of a confidential nature (as defined under 3.12.8 will not be made available on the CCG’s website or by application to the CCG Headquarters.

3.11.5 All meetings will ask for declarations of Conflicts of Interest at the commencement of the meeting and record any declared or which become apparent during the meeting in line with the CCG’s Conflicts of Interest policy which may be amended from time to time.

3.12 Admission of public and the press

3.12.1 Meetings of the Governing Body will be held in public, other than for business deemed to be confidential. Arrangements will accord with the Public Bodies (Admission to Meetings) Act 1960, the Freedom of Information Act 2000 and the General Data Protection Regulation (GDPR) 2018.

3.12.2 The public meetings of the Governing Body will be announced for the period ahead via the Clinical Commissioning Group’s website. The agenda papers of upcoming meetings and previous meetings (including minutes as approved) will be available on the Clinical Commissioning Group’s website.

3.12.3 Rooms used for Governing Body meetings will allow for the presence of members of the

public. Those who attend have no right to speak other than by invitation from the Chair. Members of the Public are requested to submit any questions they wish to pose to the Clinical Commissioning Group’s Headquarters using the proforma provided at the meeting. Alternatively, there will be an opportunity for members of the public both before and after the meeting to meet with members of the Governing Body.

3.12.4 The Governing Body must pass the following resolution to exclude the public on the grounds of confidentiality: ‘That representatives of the press and other members of the public be excluded from the remainder of this meeting due to the confidential nature of the business to be transacted - publicity on which would be prejudicial to the public interest’.

3.12.5 In the event the public could be excluded from a meeting of the Governing Body pursuant to Standing Order 3.13.4, the group shall consider whether the subject matter of the meeting would in any event be subject to disclosure under the Freedom of Information Act or any such similar Act(s) or directive(s), and if so, whether the public should be excluded in such circumstances.

3.12.6 The Chair (or Vice Chair if one has been appointed) of the person presiding over the meeting shall give such directions as he/she thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Governing Body’s business shall be conducted with interruption or disruption, and without prejudice to the power to excluded on the grounds of the confidential nature of the business to be transacted, the public will be required to withdraw upon the Governing Body resolving: ‘That in the interests of public order the meeting adjourn for (the period to be specified) to enable the Governing Body to complete its business without the presence of the public’. Section 1(8) of the Public Bodies (Admissions to Meetings) Act 1960’.

3.12.7 Matters to be dealt with by the Governing Body following the exclusion of representatives of the press, and other Members of the public shall be confidential to the Members of the Governing Body.

3.12.8 Members and Officers or any employee of the Governing Body in attendance shall not reveal or disclose the contents of papers marked ‘in confidence or confidential’ or minutes headed’ Items Taken in Private’ outside of the Governing Body, without the express permission of the Governing Body. This prohibition shall apply equally to the content of any discussion during the Governing Body meeting which may take place on such reports or papers.

3.12.9 Nothing in these Standing Orders shall be construed as permitting the introduction by the public, or press representatives, of photographing, recording, transmitting, video or similar apparatus into meetings of the CCG or Committee thereof. No Such permission shall only be granted upon resolution of the CCG.

3.13 Members’ Forum

3.13.1 Calling meetings

The Membership of the CCG will meet as a Membership Forum, at which GPs and member practices will hold the Governing Body of the CCG to account at least four times a year. The Membership Forum shall be facilitated by the CCG. The Membership Forum shall also meet on an ad hoc basis to consider matters of common interest and to procure dispute resolution.

3.13.2 Agenda, supporting papers and business to be transacted

Items of business to be transacted for inclusion on the agenda of a meeting need to be notified to the Chair of the Membership Forum at least six 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 six working days before the meeting takes place. The agenda and supporting papers will be circulated to all members of a meeting five working days before the date the meeting will take place.

3.13.3 Selection of the Chair

The selection of the Membership Forum Chair shall be by nomination and or expression of interest from the membership of NHS Lincolnshire CCG. The Chair must be a GP. Engagement of the nominations and or expressions of interest will take place with the membership. The Chair will be elected by the membership of NHS Lincolnshire CCG.

3.13.4 Chair's ruling

The decision of the Chair of the Membership Forum on questions of order, relevancy and regularity and their interpretation of the Constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final.

3.13.5 Quorum

The quorum necessary for the transaction of the Membership Forum business shall be 13 of the members.

The members may nominate a deputy to attend on their behalf. The nomination must be approved by the Chair. Where a nominated deputy attends, the nominated individual will have delegated responsibility for representation at the Membership Forum including voting, actions as required and any decisions made.

3.13.6 Decision making

Section 5 of the CCG’s Constitution, together with the scheme of reservation and delegation, sets out the governing structure for the exercise of the CCG’s statutory functions. Generally it is expected that at the Membership Forum meeting 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:  Eligibility – 25 Practice Representatives  Majority necessary to confirm a decision – Majority of votes cast. Should a vote be taken the outcome of the vote, and any dissenting views, must be recorded in the minutes of the meeting.

3.13.7 Emergency powers and urgent decisions

Where an urgent decision or approval needs to be made before the next scheduled meeting of the Membership Forum a “virtual” decision can be made by contacting all voting members, usually by electronic means, including all the relevant information for them to make an informed decision. There must be a majority response to the proposals which must be quorate in line with the Terms of Reference (and as defined under 3.13.6) Any decision must be reported to the next meeting of the CCG Governing Body.

3.13.8 Record of Attendance

The names of all members of the meeting present at the meeting shall be recorded in the minutes of the Membership Forum.

3.13.9 Minutes

The names and designation of all members of the Membership Forum present shall be recorded in the minutes of the respective Membership Forum meetings. All meetings will ask for declarations of Conflicts of Interest at the commencement of the meeting and record any declared or which become apparent during the meeting in line with the CCG’s Conflicts of Interest policy which may be amended from time to time.

3.13.10 Annual General Meeting

The Annual General Meeting of the CCG will be held in public for presentation of the Annual Report and Annual Accounts with members of the Governing Body present. A substantial proportion of this meeting time will be given over to hearing and responding to the views and questions of the public.

4. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES

4.1. Appointment of committees and sub-committees

4.1.1. The CCG may appoint committees and sub-committees of the CCG, subject to any regulations made by the Secretary of State, and make provision for the appointment of committees and sub-committees of its Governing Body. Where such committees and sub-committees of the CCG, or committees and sub-committees of its Governing Body, are appointed they are either defined in the CCG Constitution under Section 5 or in the CCG Governance Handbook. 4.1.2. Other than where there are statutory requirements, such as in relation to the Governing Body’s Audit Committee, Remuneration Committee or Primary Care Commissioning Committee, the CCG shall determine the membership and Terms of Reference of committees and sub-committees and shall, if it requires, receive and consider reports of such committees at the next appropriate meeting of the CCG.

4.1.3. The provisions of these standing orders shall apply where relevant to the operation of the Governing Body, the Governing Body’s committees and sub-committee and all Committees and Sub-Committees unless stated otherwise in the committee or sub- committee’s Terms of Reference.

4.2. Terms of Reference

4.2.1. Terms of reference shall have effect as if incorporated into the Constitution Appendices and in the CCG Governance Handbook. Terms of References are published on the CCG’s website at to be inserted.

4.3. Delegation of Powers by Committees to Sub-committees

4.3.1. Where committees are authorised to establish sub-committees they may not delegate executive powers to the sub-committee unless expressly authorised by the Governing Body.

5. DUTY TO REPORT NON-COMPLIANCE WITH STANDING ORDERS AND PRIME FINANCIAL POLICIES

5.1. If for any reason these standing orders 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 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 Accountable 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: c) The Accountable Officer; d) The Chief Finance Officer; and e) Any senior Officer authorised by the Accountable 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. c) The Accountable Officer; d) The Chief Finance Officer; and e) Any senior Officer authorised by the Accountable Officer.

7. OVERLAP WITH OTHER CLINICAL COMMISSIONING GROUP POLICY STATEMENTS / PROCEDURES AND REGULATIONS

7.1. Policy statements: general principles

7.1.1 The CCG will from time to time agree and approve policy statements / procedures which will apply to all or specific groups of staff employed by NHS Derby and Derbyshire Clinical Commissioning Group. The decisions to approve such policies and procedures will be recorded in an appropriate group minute and will be deemed where appropriate to be an integral part of the CCG’s standing orders.

Appendix 4: – Delegated Financial Authority Limits

Annex 1: Decisions, Authorities and Duties Delegated to Officers of the CCG Governing Body

1.1. The arrangements made by the CCG as set out in the Overarching Scheme of Reservation and Delegation of decisions shall have effect as if incorporated in the CCG’s Constitution.

1.2. The CCG remains accountable for all of its functions, including those that it has delegated.

1.3. The Overarching Scheme of Reservation & Delegation (Schedule of Matters Reserved to the CCG and Scheme of Delegation) and details the arrangements made by the CCG for discharging its functions.

1.4. The Schedule below details the Operational Scheme of Delegation (and financial authority limits). These should be read in conjunction with the Prime Financial Policies (See CCG Governance Handbook).

1.5. This is prepared by the Accountable Officer and sets out those key operational decisions delegated to individual employees of the CCG

1.6. The approval of the CCG’s Operational Scheme of Delegation that underpins the CCG’s “Overarching Scheme of Reservation and Delegation”, is reserved to the Governing Body.

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 1. Capital Projects and Assets 1.1 Approval of capital business cases This includes cases that may receive including leases external funding. These powers may not be further delegated. In the absence of All PFI schemes and other schemes Governing Body the appropriate officer authorisation greater than £250,000 must be obtained from the level above.

Up to £250,000 Finance Committee In urgent cases- joint approval by the Accountable Officer and Chief Finance Officer required ( up to limits of approval by the Clinical Executive Committee)

Approval would be required for granting, terminating or extending leases.

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 1.2 Capital expenditure variations In urgent cases- joint approval by the Variation over the original business case Accountable Officer and Chief Finance figure: Officer required ( up to limits of approval by the Clinical Executive Committee) Greater than £100,000 Governing Body

Greater than £25,000 and less than £100,000 or greater than 5% of the Finance Committee original business case whichever is the lower

Chief Finance Officer Less than £25,000 or less than 5% of the original business case whichever is the lower

1.3 Maintenance of the capital asset register Chief Finance Officer Head of Finance

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 1.4 Approval of asset disposals:

Land and buildings Governing Body

Other Assets, where asset has a residual

value: Deputy CFO must always be informed

to enable the asset register to be Greater than £100,000 Governing Body updated.

£50,000 and up to £100,000 Accountable Officer Disposals include those items that are

obsolete, obsolescent, redundant, £10,000 but less than £50,000 Less Chief Finance Officer irreparable or cannot be repaired cost than £10,000 Executive Directors effectively.

Other – where the asset has no residual Deputy Director of Finance value

2 Contracts

2.1 Financial appraisal of companies Chief Finance Officer Delegated to Chief Finance Officer identified as potential tenders

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 2.2 Authorisation of less than the requisite The requisite number of tenders / number of tenders / quotes: For all quotes: contracts of £250,000 and above Accountable Officer Chief Finance Officer a) Up to £20,000, at least 3 written For all contracts less than £250,000 competitive quotations for goods / Including Capital projects / Works services obtained Goods and Services b) From £20,000 to £50,000, at least 5 written competitive quotations for goods / services obtained c) Above £50,000, a full tender is to be carried out.

2.3 Authorisation of single tender / single quote Where a single tender / single quote is action: sought or received, the CCG shall as far as practical, determine that the price to be For all contracts of £250,000 and above Accountable Officer paid is fair and reasonable and that (Illegal under EU Regulations) details of the investigation are recorded.

For all contracts less than £250,000 but Where a single tender / single quote is Chief Finance Officer above £4,000 (illegal under EU authorised, this will be reported at the Regulations if above EU Threshold) next audit committee. including Capital projects / Works Goods and services

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 2.4 Single tender / single quote action for maintenance or other support contracts for Delegated to Deputy CFO, who will existing goods or assets where the CCG is Chief Finance Officer maintain a register of such contracts contractually tied to specific companies. approved.

2.5 Monitoring of the use of single tender / Audit Committee on behalf of Appropriate records to be maintained by single Governing Body the Chief Finance Officer as the basis for quote action. reporting, delegated to Head of Finance. A CCG Waiver must be completed and forward to the Head of Finance.

2.6 Advertising of contracts/awards: Accountable Officer Delegated to the CCG Procurement - Must be advertised, lead - The CCG Procurement Manager will co-ordinate this via the appropriate web portal

2.7 Opening of tenders (will be automatic Any two from “List of CCG officers once web portal is being used for authorised to open tenders” where advertising of all tenders) tender is over £50,000. Any one from list where tender is below £50,000.

2.8 Permission to consider late tenders Accountable Officer

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 2.9 Tender ratification and award, including authorisation of any actions resulting from post tender negotiations:

All types of tenders (on the lifetime value of the contract): Budget Holder – Exec Director a) Up to £50,000

b) Above £50,000 Accountable Officer Finance i. Non-clinical spend Committee ii. Clinical spend up to £1,500,000 Governing Body iii. Clinical spend above £1,500,000

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 2.10 Signing of service provision contracts including letters of intent (the below is based on the lifetime value of the contract). This includes NHS, independent care placements, private sector and non-healthcare contracts Accountable Officer AND Chief All Works contracts of £500,000 Greater than £10 million Finance Officer and above should be sealed; other Accountable Officer contracts should be sealed if in the Greater than £1 million and up to £10 interests of the CCG. million Chief Finance Officer

Greater than £100,000 and up to £1 million Budget Holders – Exec Directors

Less than £100,000

2.11 Approval of variations or extensions to In all contracts the CCG should contracts: endeavour to obtain best value for

money. See 2.10 above

2.12 Sealing of documents Subsidiary pages of Works contracts to be Chair (or Vice-Chair in the absence of signed in accordance with Power of the Chair) and one Executive Director Appointment procedure

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION Income Generation and Research and 3 Development Contracts 3.1 Approval of income generation contracts and variations or extensions to income generation contracts: These powers may not be further Governing Body delegated; in the absence of the Greater than £500,000 appropriate officer authorisation must be obtained from the level above Accountable Officer £250,000 and up to £500,000

Less than £250,000 Chief Finance Officer

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 3.2 Approval of research and development These powers may not be further contracts delegated.

(including variations or extensions) Governing Body In the absence of the appropriate Greater than £500,000 officer authorisation must be Accountable Officer obtained from the level above £250,000 and up to £500,000 Chief Finance Officer Up to £250,000

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 4 Purchasing and Payments (excl. Payroll)

4.1 Non Pay Expenditure for healthcare contracts that have been signed and ratified by the governing body

Greater than £50 million Accountable Officer following Governing Body approval

Greater than £ 1 million up to £50 million Budget Holder – Exec Director, or In line with budget management Accountable Officer / Chief Finance responsibilities (i.e. delegated budgets) Officer and subject to quoting & tendering as Greater than £50,000 to £1 million Budget Manager – Functional required (see Section 2 above) Director

Up to £50,000 Senior Manager – Band 8a or above

Exceptional: CHC under £10,000 CHC Head of Programme Finance Exceptional: NCAs under £1,000 Financial Accountant

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 4.2 All Other Non Pay ( Limits include VAT) Authorisation of internal requisitions and invoices: Greater than £50 million

Accountable Officer following Greater than £ 1 million up to £50 million Governing Body approval

Greater than £50,000 to £1million Accountable Officer / Chief Finance Officer These limits are the maximum limits for each delegated group and at any time, as

deemed necessary, the Chief Finance Up to £50,000 Chief Finance Officer Officer can impose lower limits for each

delegated group.

For further information please refer to Exceptional: CHC under £10,000 CHC Head of Programme the Authorised Signatory Policy Exceptional: NCAs under £1,000 Finance Deputy Chief Finance Officer Procurement of Professional Services (additional controls are required due to the nature of expenditure): Accountable Officer, Deputy - Legal advice Accountable Officer or CFO. - Specialist advice - Specific projects

100

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 4.3 Authorised list “List of CCG officers Authorisation of official orders permitted to authorise official orders” (maintained by Chief Finance Officer)

4.4 Authorisation for re-imbursement in line Authorisation of petty cash payments with procedures as outlined in the Authorised Signatory Policy

Disbursements up to £50 Budget Holder – Exec Director

5 Payroll Expenditure 5.1 Pay including substantive/agency Remuneration Committee (excluding timesheets) within establishment Prior to incurring pay expenditure which Substantive staff on VSM contracts Accountable Officer and Chief includes agency, interim and temporary Finance Officer staff, the CCG’s Establishment All Off-payroll / Agency staff where: Accountable Officer and Chief Finance Vacancy Control Process must be - Cost is less than £600/day (excl. VAT) Officer and NHS England. followed as well as the Temporary - Engaged for less than 6 months Staffing Policy incorporating escalation - And not in roles of significant policies for rates outside either influence. Where any of the above are not met framework or NHSE caps. Once Chief Finance Officer approved by the Establishment Control process the following delegated limits apply. All other pay expenditure up to VSM rates Accountable Officer and Chief Finance Officer

101

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION Engagement of Staff not within Governing Body Establishment

Authority to appoint staff Accountable Officer and Chief Finance Officer

Authority to permanently amend the Accountable Officer and Chief Finance formal establishment Officer

All Off-payroll / Agency staff where: Accountable Officer and Chief - Cost is less than £600/day (excl. VAT) Finance Officer - Engaged for less than 6 months - And not in roles of significant Chief Finance Officer and Budget influence. Holder – Exec Director (within Where any of the above are not met financial budget)

Engagement of CCG’s solicitors Chief Finance Officer

Booking of bank staff from approved lists Budget Holder - Exec Director

102

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 5.2 Authorisation of travel claims ( Mileage) Line Managers with Delegated Signatory as outlined in the Authorised Any expenses claimed by the Signatory List Chair shall be authorised by the Accountable Officer and any expenses claimed by the Accountable Maximum value of any single monthly claim Authorisation for claims older than 3 Officer shall be authorised by the Chair of is restricted to £2,500 with no claims being months can be delegated to the Deputy Chief Finance Officer. older than 3 months unless approved by Chief Finance Officer either the Chief Finance Officer or Accountable Officer.

5.3 Authorisation of other travel and other allowances outside the CCGs Expenses Policy Accountable Officer See Travel & Expenses Policy for Authorisation of other travel and other details of other allowable expenses. allowances as per the CCGs Expenses Policy Any study leave and associated Over £300 expenses should be agreed by the CFO and Budget Holder – Exec Accountable Officer or Chief Finance Up to £300 Director in advance. Officer Up to £100 Budget Holder – Exec Director

Budget Manager – Functional Director No claims being older than 3 months Can be delegated to the Deputy Chief unless approved by either the Finance Finance Officer Director or Accountable Officer.

103

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 5.4 Authorisation of payroll timesheets

Maximum value of any single monthly claim Delegated Line Managers. See Authorised Signatory Policy is restricted to £2,500 with no claims being older than 3 months unless approved by Authorisation for claims older than 3 either the Finance Director or Accountable months can be delegated to the Deputy Officer. Chief Finance Officer

6 Income/debt write-off 6.1 Authorisation of credit notes

Greater than £500,000 Governing Body

£250,000 and up to £500,000 Accountable Officer or Chief Finance Officer Greater than £5,000 but less than Deputy Chief Finance Officer £250,000

Budget Managers Up to £5,000 6.2 Authorisation to refer debts to debt Chief Finance Officer Delegated to Head of Financial collection agency Accounts/Deputy Chief Finance Officer

104

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 6.3 Authorisation of debt write-off: Individual debts All write offs to be reported to the Audit Committee Greater than £10,000 Governing Body

Greater than £5,000 and up to £10,000 Up Accountable Officer

to £5,000 Chief Finance Officer

7 Losses and special payments

7.1 Authorisation of losses and special payments, All losses greater than £100,000 must be including ex-gratia payments: approved by Treasury. See losses procedure contained in the General Greater than £50,000 Governing Body Financial Procedures. After advice taken by lawyers. £10,000 and up to £50,000 Accountable Officer

The Chief Finance Officer will report any Up to £10,000 Audit Committee or in an emergency Chief Finance Officer or Deputy Chief cases they consider to be “novel, Finance Officer contentious or repercussive” to the Chair of the Audit Committee as soon as they become aware of the case. And should be reported to NHS England in line with guidance.

105

7.2 Authorisation of clinical negligence payments - Up to the CNST excess Chief Finance Officer - Above the CNST excess Governing Body

106

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 7.3 Monitoring of losses and special Audit Committee Liaison with the CCG’s Local Counter payments Fraud Specialist & Police as required and in line with the CCG’s Fraud, Corruption and Bribery Policy.

7.4 Authorisation of early retirement, redundancy and other termination payments to staff: Governing Body and Remuneration Greater than £100,000 Committee

£50,000 and up to £100,000 Accountable Officer

Up to £50,000 Chief Finance Officer

8 Budgetary Control

8.1 Approval of budgets and resources Governing Body The approval of budgets and resources will usually take place Delegation of budgets Accountable Officer and Chief during the March Governing Body Finance Officer meeting.

Approval to spend Budget Holder / Manager is permitted to incur costs in accordance with their budgets & authorisation limits

107

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 8.2 Approval of budget virements Virements within a budget holders If Virement is the result of an approved budget are permitted in authorised contract variation accordance with virement rules, as Greater than £100,000 Accountable Officer, Chief Finance set out by the Chief Finance Officer. Officer, Deputy Chief Finance Officer

Greater than £25,000 up to £100,000 Executive Director

Greater than £500 up to £25,000 Budget Holder

£500 and below Budget Manager

For other virements

Greater than £10,000 Clinical and Lay Commissioning Committee Up to £10,000 A Business Case is required. Budget Holder

8.3 Approval of transfers from reserves Chief Finance Officer

108

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 8.4. Approval of Revenue Business Cases (not Capital) In urgent cases- joint approval by the Accountable Officer and Chief Finance Governing Body Greater than £500,000 Officer required ( up to limits of approval by the Clinical Executive Committee) Up to £500,000 Finance Committee

9 Stores 9.1 Management and control of stores:

General Executive Director of Corporate Delegated to CCG Procurement Strategy and Delivery Manager

Pharmacy Medical Director 10 Bank accounts and payment methods 10.1 Opening of bank accounts or changes to Chief Finance Officer Governing Banking Services only. banking arrangements. Should be reported to the next Governing Body meeting. 10.2 Signing of cheques for cash, signing of See authorised signatory list Lists to be maintained by the Chief other cheques, and authorisation of Finance Officer electronic payments ,cheque and BACs payment schedules

11 Fees and charges 11.1 Approval of fees and charges Chief Finance Officer Examples are course fees, mobile phone use, private use of NHS equipment and facilities (such as photocopiers and rooms).

109

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 12 Standards of business conduct 12.1 Maintenance of the CCG Register of Chief Finance Officer Interests Maintained by CCG Secretary

12.2 Maintenance of CCG Gifts and Hospitality register Chief Finance Officer Maintained by CCG Secretary

13 Insurance 13.1 Decision of level of and claims against Non Chief Finance Officer The risk should be managed by the Clinical Insurance Accountable Officer, in conjunction with the CCG’s Lead for Governance. 13.2 Decision of level of and claims against Clinical Chief Finance Officer The risk should be managed by the Insurance Accountable Officer, in conjunction with the CCG’s Lead for Governance. 14.0 Fraud and Irregularity 14.1 Counter fraud and corruption work in Chief Finance Officer In liaison with Local Counter Fraud accordance with Secretary of State’s Specialist, Counter Fraud Operational Directions Service and Police as appropriate

14.2 Investigation of suspected cases of Chief Finance Officer irregularity not related to fraud or corruption 15 Investments 15.1 Approval of Investment Policy Governing Body 15.2 Investment decisions Chief Finance Officer 16 Borrowing

110

RESPONSIBILITY DELEGATION ARRANGEMENTS FURTHER INFORMATION 16.1 Approval of loans:

All Loans Governing Body

111

Annex 2: Conflicts of Interest Management

On 16 June 2017, NHS England published revised statutory guidance on managing conflicts of interest for CCGs. This replaces the 2016 version of the guidance.

The guidance has been updated to ensure it is fully aligned with the recently published cross system conflicts of interest guidance – Managing conflicts of interest in the NHS: Guidance for staff and organisations. A small number of changes have been made including:

 Registers of interest: We have updated the CCG guidance to require that CCGs have systems in place to satisfy themselves as a minimum on an annual basis that their registers of interest are accurate and up-to-date, and to require that only decision-making staff are included on the published register.  Gifts from suppliers or contractors: In line with the NHS-wide guidance, gifts of low value (up to £6), such as promotional items, can now be accepted.  Gifts from other sources: We have amended the thresholds so that gifts of under £50 (rather than £10) can be accepted from non-suppliers and non- contractors, and do not need to be declared. Gifts with a value of over £50 can now be accepted on behalf of an organisation, but not in a personal capacity.  Hospitality – meals and refreshments: We have amended the thresholds so that hospitality under £25 does not need to be declared. Hospitality between £25 and £75 can be accepted, but must be declared, and hospitality over £75 should be refused unless senior approval is given.  New care models: We have included a new annex to provide further advice on identifying, declaring and managing conflicts of interest in the commissioning of new care models: Annex K: Conflicts of interest and New Models of Care.

112

NHS LINCOLNSHIRE EAST CCG GOVERNING BODY PUBLIC MEETING

Report to: NHS Lincolnshire East CCG Agenda item: 7b Date of Meeting: 23 January 2020

Title of Report: Healthwatch Report - Impact of poor communication on patients, carers and service users Status of report: For discussion (decision and approval, position statement, information, confidential discussion) Lead Director: Lyndy Moulder Author: Sarah Fletcher, CEO and Dean Odell, Healthwatch Contact Coordinator Appendices: 1 report

1. Purpose of the Report (including link to objectives) To share with Lincolnshire East Governing Body a discussion paper with regards to the impact of poor communications via NHS services

2. Recommendations To consider the outcome of discussions and feedback to Healthwatch Lincolnshire

3. Background Every month Healthwatch Lincolnshire receives feedback from the public about poor communication from their health and care services and how it impacts on their mental wellbeing and ultimately physical health. As a response, in our monthly patient feedback reports, we have regularly highlighted individual patient’s experiences with regards to their impact poor communication is having on them.

To provide some context to this issue, over the past year alone, Healthwatch Lincolnshire has received 615 public experiences with their concerns about how services communicate with them. These experiences can be broadly categorised in 3 ways:

1. Administration 2. Verbal 3. General information

4. Summary of Key Issues for Discussion N/A

5. Care Quality Commission Implications: N/A

1 6. Legal/NHS Constitution Considerations N/A

7. Analysis of Risk including the link to the Board Assurance Framework and Risk Register N/A

8. Resource Implications (Financial and Staffing) N/A

9. Patient, Public and Stakeholder Involvement Patient, public and stakeholder involvement is an essential requirement of Healthwatch statutory obligations. Our reports are constructed with the voices of patient, user and carer lived experiences and provide ‘real time’ data as to the experiences of access to and services by primary care, secondary care, community health and social care providers in Lincolnshire.

10. Equality and Diversity Impact DUE REGARD TO THE PROACTIVE DUTIES OF THE EQUALITY ACT 2010 HAS BEEN TAKEN IN DEVELOPMENT OF THIS PAPER NOTE: Policies/decisions may need to be adjusted in line with any Equality Analysis or Due Regard that is brought back at a future date. Any decision that is finalised without being influenced by appropriate Due Regard could be deemed unlawful.

11. Health Inequalities Impact

12. References to previous reports Healthwatch Lincolnshire have been producing monthly, themed and Enter and View reports since May 2014. Previous reports can be either downloaded from our website, or hard copies available on request to our office (address below).

13. Freedom of Information Subject to FOI

14. For further information or for any enquiries relating to this report, please contact Sarah Fletcher, CEO Healthwatch Lincolnshire Unit 12, 1-2 North End Swineshead Boston Lincs PE20 3LR Tel: 01205 820892 Email: [email protected] Web: www.healthwatchlincolnshire.co.uk

2 Healthwatch Lincolnshire report to East, South, South West and West CCG, January 2020

Impact of poor communication on patients, carers and service users Every month Healthwatch Lincolnshire receives feedback from the public about poor communication from their health and care services and how it impacts on their mental wellbeing and ultimately physical health. As a response, in our monthly patient feedback reports, we have regularly highlighted individual patient’s experiences with regards to their impact poor communication is having on them. To provide some context to this issue, over the past year alone, Healthwatch Lincolnshire has received 615 public experiences with their concerns about how services communicate with them. These experiences can be broadly categorised in 3 ways: 1. Administration, e.g. appointment letters Example of patient feedback: “Patient received 2 letters on the same day for Bowel Screening. First letter opened dated 20 November informing the patient that as they had heard nothing the appointment for the service was cancelled. On opening the next letter, which arrived on the same day, was dated 12 November it was a letter of invitation to Bowel Screening for a December date.” (Case 8107) “I recently had an appointment letter for the next day at the hospital, while this would be great for some people, some of cannot get time off work at such short notice. So the appointment had to be cancelled.” (Case 7627) Too often patients are contacting Healthwatch to share their concerns about the number of appointment letters (often sent on the same day) they have received. In many cases this leads to confusion as to when their appointment is, and worst still the patient finds they have been removed from clinic list by not turning up for an appointment they had no knowledge of. Appointment letters refer mainly to hospital appointments and NHS screening. Healthwatch Lincolnshire report to East, South, South West and West CCG, January 2020

Other difficulties concern the format of correspondence, for example, where patients with a known sight problem or a learning difficulty receive totally inappropriate written communication. 2. Verbal, eg patients receiving information from doctors, consultants unsure of what is being said Example of patient feedback: “Lack of communication between the hospitals and patients especially if clinics are running late. Signage can be confusing for people. Many expressed that they have got to a clinic to be informed that the Doctors have not arrived yet, but no information given to patients on arrival unless they ask.” (6329) “I was waiting for the results of a biopsy and had an appointment to see the Consultant. The day before this appointment, the patient received a letter which more or less confirmed the result of the biopsy. Thought this was out of place considering the result and would have been better given by the Consultant at the appointment the following day. The Consultant was surprised the patient was already aware of the biopsy results. At the time of seeing the Consultant, patient was given a lot of paperwork about the way forward, patient felt this should have been verbally explained because they had a lot of questions.” (7157) Patients, carers and service users are often afraid, concerned or just too poorly to fully take on board everything that is being said to them during a consultation. Sometimes due to communication problems a patient, carer or service user cannot understand everything that is being discussed. They are not always confident enough to ask a nurse, doctor, consultant or other medical professional to repeat or confirm what has been said. This leads to them coming away unsure of what the next steps are. 3. General, eg leaflets, posters, signage, these can include information that is out of date or not meeting the needs of individuals Example of patient feedback: “Patient who is Deaf/Blind and uses an assistance dog had been asked by a Consultant at Pilgrim Hospital to leave their dog outside on the Consultants religious grounds. The patient requires their dog to keep them safe. Access to interpreters for people living with hearing loss, ‘there are not enough of them available’. Often patients have their appointments cancelled due to not being able to access this service. Not everyone has someone that they can bring with them at the last moment. Access to services at the ULHT buildings for many people with sensory loss (sight and hearing) more consideration needs to go into how the lighting is used or not used. For people who use sign language as their main form of communication, going for an eye appointment in a darker room (understandable for the examination) but the patient is not able to "see" their interpreter so there will be a breakdown in communication.” (8113) Healthwatch Lincolnshire report to East, South, South West and West CCG, January 2020 Over the past few years we have received feedback from patients, carers and service users telling us that general information such as telephone numbers are incorrect or out of service; that advertised services are no longer available; that signage in departments is poor or not ‘friendly’ to service user needs, specifically hearing or sight impairments and English as a second language. Accessible Information Standards and Easy Read From 1 August 2016, all organisations that provide NHS care and/or publicly-funded adult social care are legally required to follow Accessible Information Standards. The standards sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users carers and parents with a disability, impairment or sensory loss (NHS England https://www.england.nhs.uk/ourwork/accessibleinfo/). What Healthwatch Lincolnshire is hoping will improve? On behalf of the public in Lincolnshire, we are asking for organising including commissioners and providers to consider:

 Administration – there is a countywide focus and investment to radically and tangibly improve administration systems at pace. Ensuring consistency in format and style, use of plain English and easy read; checking processes to avoid errors in sending out duplicate letters, and where appointments are cancelled and rescheduled that there isn’t a reliance on post to get the message to patients. We would hope taking this approach would lead in the long term to cost savings with the significant reduction in unnecessary administration.  Verbal – there is a countywide agreement to ensure patients, carers and service users are automatically asked before they leave all consultations that they fully understand what has been discussed and what is happening next, even practical solutions such as offering a pen and paper would be supportive of this process.  General – there is a countywide focus on ensuring information is regularly audited and where out of date removed and replaced as soon as possible. That signage is clear and appropriate to the audience; that individual patients, carers and service user needs are requested, recorded and acted upon to ensure any future support is offered in an appropriate formats. We appreciate this might be a big ask but suggest setting up a volunteer support scheme to help assess public information is up to date could be one way forward. Healthwatch welcomes feedback regarding this discussion paper

NHS LINCOLNSHIRE EAST CCG GOVERNING BODY MEETING

Report to: NHS Lincolnshire East CCG Agenda item: 7c Governing Body Date of Meeting: 23 January 2020

Title of Report: Report on Quality Oversight ULHT Status of report: Discussion/Information (decision and approval, position statement, information, confidential discussion) Lead Director: Elizabeth Ball, Chief Nurse Author: Sarah Southall Deputy Chief Nurse Appendices

1. Purpose of the Report (including link to objectives)

This report has been written to provide the Governing Body with an oversight to the system’s response to United Lincolnshire Hospitals NHS Trust latest CQC unannounced inspection which commenced on 11 June 2019, and the Well Led inspection which commenced on 15 July 2019. ULHT returned to Special Measures following their CQC inspection in October 2016, and the subsequent visit in February and April 2018.

In addition the report has been written to provide the Governing Body with information relating to the current position reported by the Trust and any on-going quality concerns.

2. Recommendations

The Governing Body are asked to consider this paper and if appropriate make recommendations about the future arrangements for monitoring and supporting ULHT to make the essential improvements in the quality of the services provided to patients.

3. Background

Following the inspection in October 2016 the CQC found that improvements noted within the organisation during the February 2015 inspection had not been sustained and the trust was placed back into special measures.

At this time the CQC raised a number of immediate patient safety concerns which the Trust quickly responded to.

A further inspection was undertaken on 26 of February 2018, which included an unannounced visit to Pilgrim ED on 15-17 of February 2018. The CQC completed a well-led inspection week commencing 9 of April 2018.

This report was published on 3 July 2018. At this time the CQC rated the trust as requires improvement overall. The Trust was issued with Urgent Enforcement Actions – Section 31 of the Health and Social

1 | P a g e 10/01/20 Care Act 2008 relating to PHB ED. These were regarding;  Effective systems in place for undertaking triage of patients  Escalation processes for staff when patients present in urgent care streaming  Effective systems in place to assess and monitor on-going care of patients within the department  Sufficient number of suitably qualified, skilled and experienced nurses and healthcare assistants

The CQC undertook a number of subsequent focussed inspections of the emergency department at Pilgrim Hospital Boston (PHB) on;

 30 November 2018, this report was published on the 20 December 2018  18 December 2018, this report as published on the 30 January 2019.  25 of February 2019, this report was published on the 3 of April 2019

During these inspections the CQC did not rate the service, but identified the following concerns;

Overcrowding in the department  Lack of responsiveness during pressure in the department  Appropriately competent paediatric staff in triage  Delays in clinical assessment and treatment initiation  Patient flow within the ED and the lack of acknowledgement that this was a trust wide issue  Handover delays

On 11 June 2019 the CQC undertook a further unannounced inspection, followed by the Well Led inspection which took place on 15 July 2019. As a result of these inspections the trust received feedback from the CQC in 2 letters dated 14 and 24 June 2019 and a letter detailing the feedback from the Well Led Inspection on 19 July 2019. These have both previously been reported to ULHT Trust Board and CCG Governing Bodies.

The CQC did identify some improvements and the full letters which can be seen at https://www.ulh.nhs.uk/content/uploads/2018/11/Public-Trust-Board-2-July-2019.pdf and https://www.ulh.nhs.uk/content/uploads/2018/11/Public-Trust-Board-6-August-2019-1.pdf

As a result of this CQC inspection the Trust was issued with an Urgent Enforcement Action – Section 31 of the Health and Social Care Act 2008 relating to sepsis, children and young people’s pathway through the Emergency Department (ED), and the environment for children and young people accessing ED. The Trust were required to take the following actions;

1. Sepsis  Implement an effective system to manage patients presenting with possible signs of sepsis and in line with clinical guidelines such as NICE guideline [NG51] Sepsis: recognition, diagnosis and early management  Ensure all patients presenting with signs of sepsis are treated within 60 minutes  Supply updates on how patients with patients with signs of sepsis are managed

2. Children and young people’s pathway through ED  Ensure that there is an effective system in place to clinically assess all children who present to the emergency department in line with the RCPCH Facing the Future: Standards for children in emergency care settings  All children must be triaged within 15 minutes, at the ED at Lincoln County Hospital (LCH)  Staff must be competent to undertake triage and be either a registered children’s nurse or have appropriate paediatric competencies, understand the system being used, identify and escalate clinical risks appropriately  Implement a system to effectively monitor the patient’s pathway through the department from arrival and enable the staff identified to care for children in the department to effectively locate children awaiting ongoing care and treatment

2 | P a g e 10/01/20 3. The environment for children and young people accessing the Emergency Department  The Trust must undertake a comprehensive assessment of the environment for children in all areas of the ED at LCH in line with the RCPCH Facing the Future: Standards for children in emergency care setting and complete an action plan to mitigate all risks identified

The Trust has responded to this Urgent Enforcement Action, providing an action plan identifying progress against the concerns raised by the required timeframe of 2 July 2019. The Trust has been required by the CQC to report on progress against the action plan that had been submitted.

The CQC have published this report on 17 October 2019 and rated the Trust as Requires Improvement overall.

Overall Rating for the Trust Requires Improvement Are Services Safe Requires Improvement Are Services Effective Requires Improvement Are Services Caring Good Are Services Responsive Requires Improvement Are Services Well-Led Requires Improvement

Not all services or all sites were inspected. The services inspected included:  Urgent and emergency care at LCH and PHB  Medical care at LCH and PHB  Critical care at LCH and PHB  Maternity services  Children and young people’s services inspected at PHB

The CQC have rated the Trust as the following;

Site Safe Effective Caring Responsive Well-Led Overall Lincoln Requires Requires Good Requires Requires Requires County Improvement Improvement October Improvement Improvement Improvement Hospital October October 2019 October October October 2019 2019 2019 2019 2019 Pilgrim Inadequate Requires Requires Requires Requires Requires Hospital October Improvement Improvement Improvement Improvement Improvement Boston 2019 October October October October October 2019 2019 2019 2019 2019 Grantham Good Good Good Good Good Good District July 2018 July 2018 July 2018 July 2018 July 2018 July 2018 Hospital Louth Good Good Good Good Good Good County July 2018 July 2018 July 2018 July 2018 July 2018 July 2018 Hospital Overall Requires Requires Good Requires Requires Requires Trust Improvement Improvement October Improvement Improvement Improvement October October 2019 October October October 2019 2019 2019 2019 2019

Following improvements noted at PHB this site was rated as Requires Improvement rather than Inadequate. The Trust will not progress out of quality special measures.

The Trust has reported that improvements have been made in some areas, however the change has not been made to the level they had wanted and had expected in order to deliver sustainable improvements to the quality of patient care and staff experience.

The CQC report is available from www.cqc.org.uk/provider(RWD)

3 | P a g e 10/01/20 4. Summary of Key Issues for Discussion

The System Improvement Board (SIB) was established to provide oversight on the delivery of the Trust’s Improvement Plan following the CQC inspection in October 2016 and the Trust being placed back into special measures. Its principal purpose was to support continued improvement in the trust, provide appropriate challenge to ensure that the most robust approaches are being considered, unblock system issues where these cannot be resolved in other forums and provide the system with a collective oversight of the progress against improvement within the trust and wider system.

SIB was accountable for gaining assurance directly from the trust and, where appropriate, the wider system for the delivery of the improvement programme. The Board was also to be made aware of current and emerging risks to the delivery of the improvement plan.

NHSE/I chaired a Quality Summit on the 10th December 2019, a number of actions were agreed to ensure that progress was being taken to make the required improvements, these included responses from ULHT and the wider system. It was agreed that the remit of the System Improvement Board would be reviewed at the next meeting scheduled for 14th January 2020 to ensure there was oversight of these actions. This meeting has new terms of reference and has been renamed the ULHT Improvement Assurance Meeting.

Progress Following CQC Inspection

The CQC identified that a number of areas had significantly improved during this inspection and the report identified some areas as outstanding, such as;  Critical care on at both LCH and PHB  Maternity services  Older people’s care  Care and treatment provided by most staff  Most staff understood the vision and values of the Trust

The CQC identified some specific areas of concern which were;  Urgent and emergency care at PHB and LCH. Ratings for Urgent and Emergency care at LCH have deteriorated  PHB rating in the safe domain has deteriorated from Requires Improvement to Inadequate  Children and young people’s services at PHB

The Trust reported that the CQC noted some improvement with regards to the Must Do’s and Should Do’s they are working on. These are aligned to the Integrated Improvement Plan. The Trust has reported progress against these to the ULHT Improvement Assurance Meeting on 14 January 2020.

Integrated Improvement Plan 2020-2025

The Trust have reported to the new ULHT Improvement Assurance Meeting on 14 January 2020, their Integrated Improvement Plan, 2020-2025, which identifies the key priorities for the Trust over the next 5 years. The Trust is focusing on the right things for both their patients and their staff.

The Integrated Improvement plan has replaced the Quality Safety Improvement Plan and is currently being reviewed and approved.

ULHT Integrated Performance Report

The Trust have reported the following issues in relation to quality in their Integrated Performance Report for October 2019 which can be found at; https://www.ulh.nhs.uk/about/board-meetings/tuesday-3-december-2019/

 The Trust is undertaking more focused work through core learning and bespoke training to address the inconsistent standard identified with regards to hand hygiene compliance. The Trust 4 | P a g e 10/01/20 has reported that this relates to the implementation of a modified hand hygiene compliance tool  There is 1 reported case of MRSA Bacteraemia which is currently under investigation. Lapses in care relating to peripheral IV cannula management have been identified and actions have been put into place  There have been 3 falls resulting in moderate harm  The Trust is reporting a significant increase in category 2 pressure ulcers from September. The Trust are undertaking a review of Septembers data for validation  The Trust has declared 1 Never Event for October, due to wrong site surgery in urology theatres at Lincoln. The Trust has now declared 4 Never Events for 19/20 financial year  The Trust has reported that medicine incidents causing harm has reduced for October to 8.4%  The Trust has reported they have 2 Patient Safety Alerts overdue, 1 for February and 1 for October 2019.  SHMI (May 2018-April 2019) is 109.82 and is in band 2 within expected limits  The Trust is reporting there are a number of NICE Technology Appraisals outstanding  eDD performance has improved for October and the Trust is reporting 93.8% are being sent within 24 hours and 94.5% being sent at 48 hours  The Trust is reporting that compliance with the sepsis bundle has declined  The Trust has identified a trend in increasing rate of induction of labour which is being discussed at Speciality Governance  The Trust has reported that National birth rate is falling and this is reflected in birth figures for ULHT

5. Care Quality Commission Implications:

United Lincolnshire Hospitals Trust has been rated as requires improvement by the CQC

6. Legal/NHS Constitution Considerations

Lincolnshire East CCG has a statutory duty to secure continuous improvement in health care services.

7. Analysis of Risk including the link to the Board Assurance Framework and Risk Register

Quality 1 – Failure to deliver quality services to providers. Score 16. Actions – All providers are monitored through the quality monitoring framework on a monthly basis through harm free care metrics. These reports are used to focus quality review visits. Schedule of quality review visits developed to incorporate all providers and triangulate intelligence. All serious incidents are analysed and reviewed by Executive Nurses from all 4 CCG's.

8. Resource Implications (Financial and Staffing)

The CCGs have continued to provide additional support to ULH

9. Patient, Public and Stakeholder Involvement

Healthwatch are a member of the System Improvement Board

10. Equality and Diversity Impact

Statutory Responsibility

5 | P a g e 10/01/20

11. Health Inequalities Impact

12. References to previous reports

This report supports the report submitted to previous Governing Body meetings

13. Freedom of Information

Public

14. For further information or for any enquiries relating to this report, please contact

Elizabeth Ball email [email protected] or 01522 515305 Sarah Southall email [email protected] or 01522 515305

6 | P a g e 10/01/20

LINCOLNSHIRE EAST CCG GOVERNING BODY

Report to: Public Governing Body Agenda item: 7d Date of Meeting: 23rd January 2020

Title of Report: Quality report on Northern Lincolnshire & Goole Foundation Trust Status of report: Information and discussion (decision and approval, position statement, information, confidential discussion) Lead Director: Elizabeth Ball, Chief Nurse, LECCG Author: Emma Danby, Senior Lead Nurse for Quality and Safety Sarah Southall, Deputy Chief Nurse Appendices:

1. Purpose of the Report (including link to objectives) This report has been written to provide the Governing Body with a quality and safety oversight of North Lincolnshire and Goole (NLaG) Trust.

2. Recommendations The Governing Body are asked to consider this paper and if appropriate make recommendations about the future arrangements for monitoring and supporting NLaG to make the essential improvements in the quality of the services provided to patients.

3. Background Following an inspection in November 2016 the CQC rated the trust as inadequate overall and in January 2017 the CQC issued a section 29A warning notice which stated that the quality of health care provided by the trust required significant improvement. In April 2017 the trust was placed in quality special measures. At this time the CQC raised a number of immediate patient safety concerns which the trust responded to. The trust put an action plan in place, which was monitored by CQC through regular engagement with the trust.

The CQC have subsequently undertaken a further inspection in May 2018. All services provided by the trust were inspected due to the last inspection being rated inadequate overall. This report was published on the 12th September 2018.

During this inspection the CQC identified improvements had been made and therefore the rating of the trust improved; rated as requires improvement overall, however the trust are to remain in special measures as the improvements have not been made at the pace of change expected by the CQC. Some of the concerns identified by the CQC following the inspection were:

 The trust did not always have appropriate levels of staff to ensure patients received safe care and treatment. Medical staffing not in line with national and professional recommendations in a number of services. 07/01/2020 V1

 High number of serious incidents within the medical service.  Limited evidence that staff had the skills, training and experience to provide the right care and treatment.  Not all staff were managing medicines in line with trust policy or national guidance.  Clinical validation and assessment of risk within outpatient’s waiting lists had been slow to be implemented across all specialities.  Examples found in medical care and outpatients where there had not been sufficient effective senior clinical oversight to manage risks to patients.

Examples of outstanding practice in critical care throughout the trust, in medical care at SGH and GDH, community dental and community end of life services.

CQC ratings for the trust overall:

The CQC report is available from https://www.cqc.org.uk/provider/RJL

The CQC undertook an inspection on the 24th September until the 27th September 2019 to the Trust. The following link provides the high level feedback provided to the trust following the inspection; https://www.nlg.nhs.uk/content/uploads/2019/10/NLG19268-CQC-High-Level-Feedback-following-CQC- Inspection.pdf

A draft of the full report has been received by the Trust for factual accuracy checking. The final publication of the report and ratings is expected to be January/February 2020.

4. Summary of Key Issues for Discussion

The Improving Together programme oversees the trust’s holistic improvement and change programme. Improving the actions required following the CQC inspection has been mapped to the work streams. The programme comprises of the following separate work streams; quality and safety, workforce, access and flow and finance, each have an Executive Senior Responsible Officer and Deputy Senior Responsible Officer.

Update reports on CQC actions and work plans will be shared at the Delivery and Assurance Committee (DAC) and the Quality Review meeting (QRM). East Lincolnshire CCG has representation at QRM.

The Trust provided an update on progress made against the CQC actions through the Trust’s CQC Stocktake Report that was submitted on the 5th November to the trust board. https://www.nlg.nhs.uk/content/uploads/2019/10/NLG19269-CQC-Quarter-2-Stocktake.pdf

There has been some progress with the number of actions moving to green (completed) increasing from 57 to 72 and the number of actions rated as red (not completed/behind schedule) reducing from 18 to 8. The key points to note from the report are as follows:

o compliance with annual staff appraisals o compliance with mandatory and statutory training 07/01/2020 V1

o staffing on the paediatric admissions unit meeting national standards o concerns with the backlog of patients awaiting follow up outpatient appointments o Concerns with RTT performance

Progress against the CQC actions is overseen via the Trust’s CQC Steering Group and the Improving Together Board which reports directly into the Trust Board.

In April 2019, the Trust Board approved the key priorities for the organisation for the following 12 months. These priorities were centred around six themes,

 Quality and Safety  Culture and Morale  Money  Staffing  Clinical Leadership and Clinical  Redesign and Service Improvement

Delivery against these priorities from April 2019 until September 2019 is summarised in the following report. As is demonstrated in the report, some progress has been made within these work streams. https://www.nlg.nhs.uk/content/uploads/2019/10/NLG19256-Progress-Against-Trust-Priorities-2019- 20.pdf

The Trust have reported the following issues in relation to quality in their Integrated Performance Report for November 2019 which can be found at https://www.nlg.nhs.uk/content/uploads/2019/10/NLG19258-Integrated-Performance-Report-IPR.pdf

These reports identify the following keys areas of concern, risks and performance.

Mortality

The SHMI is 118 for the period June 2018 – May 2019 which is in the ‘higher than expected’ bracket. A higher than average deaths occurring out of hospital following discharge.

Concerns have been identified with coding morbidities and recognition of end of life.

The Trust’s Mortality Improvement Group (MIG) is now Chaired by the Medical Director. The Structured Judgement review process compliance is monitored.

The following arrangements are in place to support improvement in the SHMI position:

 The Trust Mortality Improvement Group meets on a monthly basis to oversee implementation of improvements required in regard to the SHMI position.

 Improvement actions relating to Mortality are mapped to the Trust’s Improving Together Plan which is overseen by the Trust Board;

 The Trust Mortality Report is reviewed with commissioners via the NLaG Quality Review Meeting on a monthly basis.

Deteriorating patient

There has been an improvement with the compliance of completing observation on time, although performance remains under 90%

07/01/2020 V1

The trust is unable to demonstrate compliance with Sepsis 6.

Medication Safety and EPMA (Electronic Prescribing and Medicines Administration)

The trust has identified 2 key areas of concerns, omission of medications and errors involving insulin. The trust has strengthened the governance arrangements in place for the safer medication group, a dashboard has been developed and there is a roll out plan for electronic prescribing and administration.

Patient flow and reduce non-elective length of stay

The trust has identified 2 key initiatives; of the introduction of SAFER (a series of work programmes to support efficient flow and early discharge) and to meet the 7 day working requirements.

Cancer services and diagnostic reporting

This priority focuses on 2 areas; straight to test for cancer diagnostics and progress with timed cancer pathways.

Other key areas of concern identified from review of the integrated report include;

 There is a risk with staff retention and recruitment of skilled workforce, specifically in relation to Medical staff and Registered Nurses

 RTT- there is growth in the overdue follow-ups- there is concern with ophthalmology service performance the trust are reviewing outsourcing some of this work

 Cancer- there is pressure regarding the 62 day cancer metrics

 Diagnostics – continued pressures within diagnostics, specifically across MRI and CT

 Safeguarding- concern relating to mental capacity assessments and staff training

Serious Incidents

There continues to be concerns regarding the trusts digital systems and patient administration demonstrated through serious incident reporting. There have been a number of reported Ophthalmology serious incidents.

The CCG quality team attend the Serious Incident Review meetings chaired by North Lincolnshire CCG

Current governance arrangements in place are as follows;

 The Trust is in quality and financial special measures. There are scrutiny and oversight mechanisms in place to monitor the position. There is a System Improvement Board in place.

 A System Planned Care Board has been established which acts to minimise the risk to patients requiring planned care services. Lincolnshire is represented by the planned care lead from the STP.

 The A&E Delivery Board functions to manage risks in the local emergency system. Lincolnshire is represented by the urgent care team.

 The Trust is receiving support from NHSI on a number of clinical agendas within the Trust which require focused improvement.

 Contractual challenge meetings are in place with the Trust

07/01/2020 V1

5. Care Quality Commission Implications North Lincolnshire and Goole NHS Foundation Trust has been rated as requires improvement by the CQC

6. Legal/NHS Constitution Considerations Lincolnshire East CCG has a statutory duty to secure the continuous improvement of services.

7. Analysis of Risk including the link to the Board Assurance Framework and Risk Register Quality 1 – Failure to deliver quality services to providers. Score 16. Actions – All providers are monitored through the quality monitoring framework on a monthly basis through harm free care metrics. These reports are used to focus quality review visits. Schedule of quality review visits developed to incorporate all providers and triangulate intelligence. All serious incidents are analysed and reviewed by Executive Nurses from all 4 CCG's.

8. Resource Implications (Financial and Staffing) Not Applicable

9. Patient, Public and Stakeholder Involvement Stakeholder, patients and their representatives, and the public will continue to be engaged in developing, considering and helping make decisions on any proposals that could have a significant impact on service delivery or the range of health services available.

10. Equality and Diversity Impact This report demonstrates the CCGs activity to meet the requirements of the Equality Act 2010, the Specific Duties Regulations 2011 and the NHS England Equality and Diversity Council.

11. Health Inequalities Impact Not applicable

12. References to previous reports Not applicable

13. Freedom of Information Public section of Governing Body

14. For further information or for any enquiries relating to this report, please contact Elizabeth Ball Chief Nurse [email protected] 01522 515305

07/01/2020 V1

GOVERNING BODY- PUBLIC

Date of Meeting: 23 January 2020 Agenda item: 7e

Title of Report: Learning Disability Mortality reviews (LeDeR) Annual Report Report Author and Title: Rebecca Pinder, Safeguarding & Mortality Review Nurse (Local Area Contact for LeDeR) Appendices: Appendix 1: LeDeR Annual Report

1. Purpose of the Report (including link to objectives) To provide information to Governing Body members that provides assurance of the CCGs progress and actions in relation to the national programme for monitoring deaths of those people with a diagnosed learning disability and addressing inequalities in service provision for this population group.

2. Recommendations Governing Body members are requested to note the content of the paper.

3. Executive Summary The persistence of health inequalities between different population groups has been well documented, including the inequalities faced by people with learning disabilities. Today, people with learning disabilities die, on average, 15-20 years sooner than people in the general population, with some of those deaths identified as potentially linked to poor quality healthcare. The LeDeR Programme was established to support local areas to review the deaths of people with learning disabilities and identify learning from those deaths which would inform service improvement initiatives. It was implemented at the time of considerable spotlight on the deaths of patients in the NHS, and the introduction of the national Learning from Deaths framework in England 2017. The programme has been developed to review deaths of people with learning disabilities aged 4yrs and over.

The level of understanding and awareness about care and support for individuals with learning disabilities has improved. Over this year we have developed better partnerships which will facilitate joint learning and promote more coordinated care for individuals and contribute to service improvement.

Lincolnshire CCG continues to be committed to delivering the LeDeR programme. The past year has been challenging due to the initial backlog of reviews at the start of the year. Following significant engagement from all providers and commencement of the Safeguarding & Mortality Review nurse role, this has now been cleared and Lincolnshire is set to continue on its current trajectory.

NHS England have acknowledged that Lincolnshire is now in a favourable position compared to other areas across the Midlands region, Lincolnshire is rated as Green on the assurance matrix. As a result of the hard work and commitment of all involved in the LeDeR process across Lincolnshire we are now in a positive positon to consolidate learning into action and to progress into a more proactive approach to meeting the health needs of people with learning disabilities. Lincolnshire will be able to deliver targeted action and commitment to improve service delivery where required.

4. Management of Conflicts of Interest Not applicable

5. Finance, QIPP and Resource Implications Not applicable

6. Legal/NHS Constitution Considerations Statutory Duty of Quality NHS Constitution principle 4 the NHS aspires to put patients at the heart of everything it does. Equality Act 2010 – section 149

7. Analysis of Risk including Assessments

Please state if the risk is on the CCG Risk Register. Yes No X

8. Outline engagement – clinical, stakeholder and public/patient As per NHS constitution

9. Outcome of Impact Assessments Quality Impact Assessment are completed as necessary and in line with organisation protocol.

10. Assurance Departments/Organisations who will be affected have been consulted

Insert details of the departments you have worked with or consulted during the process:

Finance Commissioning Contracting Medicines Optimisation Clinical Leads Quality x Safeguarding x Other

11. Report previously presented at: Not applicable.

12. For further information or for any enquiries relating to this report, please contact Pamela Palmer, Chief Nurse [email protected] Rebecca Pinder Safeguarding & Mortality Review Nurse [email protected]

Annual Report Lincolnshire CCG Learning Disability Mortality Reviews (LeDeR) January 2019-January 2020

Report compiled by; Rebecca Pinder, Safeguarding & Mortality Review Nurse (Local Area Contact for LeDeR)

Contents

Section Page

Introduction 3

Process 4

Steering Group 5

Deaths notified in Lincolnshire to the LeDeR 5 programme

Themes, learning points and recommendations 6 from reviews Good practice examples from completed 7 reviews

Outcomes and Impact 7

Objectives and plans 2020 – 2021 10

Conclusion 12

Introduction

This is the first annual report in respect of activity and findings relating to Learning Disability Mortality Review (LeDeR) reviews undertaken for the Clinical Commissioning Groups of Lincolnshire as required by the ‘The NHS Long Term Plan January 2019’, herein referred to as the CCG’s.

The persistence of health inequalities between different population groups has been well documented, including the inequalities faced by people with learning disabilities. Today, people with learning disabilities die, on average, 15-20 years sooner than people in the general population, with some of those deaths identified as potentially linked to poor quality healthcare.

The LeDeR Programme was established to support local areas to review the deaths of people with learning disabilities and identify learning from those deaths which would inform service improvement initiatives. It was implemented at the time of considerable spotlight on the deaths of patients in the NHS, and the introduction of the national Learning from Deaths framework in England 2017.

The programme has been developed to review deaths of people with learning disabilities aged 4yrs and over. An initial review will be undertaken in all cases of a person dying who is known to have a learning disability. If an area of concern is identified during the initial review, or it is felt that further learning could be gained, a full multi-agency review will be undertaken.

In order to establish key processes to deliver mortality reviews, the CCG’s established a local steering group chaired by the Federated Safeguarding Team Designate Nurse who is also the strategic lead for the group. Oversight of the programme delivery is undertaken by the Chief Nurse for Lincolnshire South and Southwest CCGs.

Following implementation of the programme the total number of deaths received into the area far exceeded the initial prediction. This alongside identification of a lack of reviewers and difficulties with accessing case notes placed an additional challenge on delivering the programme locally.

The most significant challenge has been the timeliness with which mortality reviews have been completed, largely driven by five key factors:

1. large numbers of deaths being notified before capacity was in place locally to review them 2. existing reviewers no longer in a position to undertake reviews 3. lack of reviewers available to train and complete reviews 4. trained reviewers having sufficient time away from their other duties to be able to complete a mortality review and 5. the process not being formally mandated.

The CCG’s Safeguarding & Mortality Review Nurse commenced in post in January 2019 acting in a joint role as a dedicated reviewer to complete LeDeR reviews and as the Local Area Contact (LAC) for the LeDeR programme. The impact of this role has been significant in:

1. Completing the ‘backlog’ of pending reviews, 2. Raising awareness and promoting the LeDeR process with provider organisations, 3. Increasing the pool of reviewers, 4. Providing a robust support network for both existing and new reviewers 5. Enhancing information sharing systems with GP practices and local authorities.

As a direct result the CCG’s do not have a waiting list of reviews to be allocated and the notifications received into the area are able to be allocated within the specified timescale.

Process

Allocation of reviews:

The LeDeR programme became live in Lincolnshire on 1st October 2017. Initially the LeDeR team predicted that 33 deaths would be reported within Lincolnshire and the initial position to implement the programme was positive. The total number of deaths received far exceeded this prediction placing a challenge on delivering the programme locally.

The LAC maintains a pool of sufficiently trained reviewers to enable timely allocation and completion of reviews. There are robust arrangements in place to ensure reviewers are supported to complete reviews within their job role. The LAC contacts each reviewer prior to allocation to ensure the reviewer has capacity to undertake the review. Aspects of the review are also discussed in relation to location, cause of death and the reviewer’s knowledge and understanding of specific conditions to complete the review.

The LAC, with support from the LAC admin, is proactive in sourcing appropriate sets of notes for each review to provide a baseline of information for the reviewer and support with completion within the six month timescale. Local reviewer forums have been established and are held bi-annually.

Since October 2017 Lincolnshire have been notified of 118 deaths of which 98 have been completed, 18 are currently in progress with 2 waiting to be allocated (1 being a CDOP case). It is anticipated that Lincolnshire will achieve the 90% target of notifications completed within 6 months.

LeDeR responsibilities are incorporated into quality assurance metrics and compliance is highlighted with the relevant boards.

Steering Group

The CCG’s established a Learning Disability Mortality Review Steering group. This is chaired by the Designate Nurse for Safeguarding Adults, Children and Looked After Children. The purpose of the group is to support the LeDeR programme by:

1. Working in partnership with NHSE, NHSI and the University of Bristol 2. Work in partnership with stakeholders to ensure proportionate representation across all sectors 3. Locally guide the implementation of the LeDeR programme 4. Support the review of all deaths of people with learning disabilities 5. Assist with interpreting and analysing data from local reviews and provide a local operational response to those outcomes. 6. Monitor action plans 7. Agree protocols for information sharing 8. Share anonymised case reports pertaining to the deaths, or significant adverse events, to contribute to collective understanding of learning points and recommendations across all cases.

The LeDeR Steering Group meets quarterly and has core representation from each of the provider organisations who provide support for the programme within their organisation in addition to support for LeDeR reviewers. From January 2020 onwards this will also include a representative from Lincolnshire Public Health.

Deaths notified in Lincolnshire to the LeDeR programme.

Lincolnshire context versus regional and national findings:

Lincolnshire (last 12 Midlands (last 12 England Jan –Jun months Jul ’18- months Jul ’18 – 2019 Jun’19) Jun’19) % % % Gender Male 56 57 57 Female 44 43 43 Age group Under 45 19 9 7 45-54 15 12 13 55-64 15 24 25 65-74 32 25 24 75 and over 19 15 15 Place of death Hospital 57 58 61 Usual place of 34 34 33 residence Other 9 7 6

Cause of death

4% 13% Respiratory Related 17% 49% Sepsis

17% Cancer Cardiac Related Dementia

From the 98 completed reviews the highest cause of death is related to:

Pneumonia and respiratory conditions 49%

Sepsis - 17%

Cancer - 17%

Cardiac related - 13% (3 of which had pre-existing heart conditions)

Dementia - 4%.

This is reflective of both the findings within the National LeDeR report and of the local population for Lincolnshire. The only exception to this is deaths caused by Dementia, which is lower within the learning disability population than the general population within Lincolnshire.

Themes, learning points and recommendations from reviews

1. Learning Disability Annual Health Checks remain a concern for the LD population across Lincolnshire with clear disparity about what is being offered/ received. This is a primary focus for ‘Learning into Action’ for Lincolnshire Steering Group. A joint project is underway with Public Health Division Lincolnshire County Council, Lincolnshire Partnership Foundation Trust LD community team, Experts by Experience and the CCG to produce a campaign specific to the LD Health check.

2. Better recording and implementation of the Mental Capacity Act; this aligns to a National Recommendation. In some cases where a decision was made there was a lack of formal Capacity assessment even when a discussion had been had with the family. A DNACPR/ReSPECT form was in place and properly completed except there was no separate assessment of capacity in the notes as per policy and no attempt to discuss with the patient was recorded.

3. Use of reasonable adjustments. Patients were invited to attend for health checks at the GP practice via letter however it was documented that the patient could not read or write; there was no evidence of provision of a reasonable adjustment to address this. Non-verbal patients were not supported to use alternative tools to express pain.

Good practice examples from completed reviews

1. Staff were fundamental to the patient receiving an initial diagnosis of testicular and subsequent diagnosis of pancreatic cancer. Knowledge and expertise of staff noticing the behaviour changes of the patient when he was ill ensured timely referrals to specialist services.

2. Health passports in place and shared appropriately, supporting the patient in attending all health appointments.

3. Personalised care and support plans in place, care staff and GP responsive to changes in health needs, prompt decision making & referrals made. Involvement of befriender to support the patient.

4. Good support from GP and the hospital both were responsive to the patient’s needs and involved the patient in the end of life care and decisions.

Outcomes & Impact

LeDeR Recommendation Detail of related local How will this impact on initiatives the delivery of health and/ or care for people with a learning disability? Strengthen collaboration The collaboration, At strategic level, the and information sharing, communication and Steering Group will effective communication, information sharing is continue to take between different care promoted by the accountability for providers or agencies. established LeDeR strengthening steering group with strong communication and

representation from the partnership working, health and care sector, especially around areas that meets regularly to that the LeDeR reviews discuss any action, have identified as learning and concerns. recommendations from the completed LeDeR reviews in order to drive service improvements across the whole system. Push forward the There is a local ‘care The portal will link data electronic integration of portal project’ and between healthcare health and social care timescale to link patient records. records to ensure that records across health agencies can providers to share and communicate effectively, communicate effectively. and share relevant information in a timely way. Health Action Plans, Locally there is a core The project will improve developed as part of the project linked to the wider the uptake and quality of Learning Disabilities learning disabilities work the LD health checks Annual Health Check across the system to across the health care should be shared with improve both the uptake community. relevant health and social and quality of LD health care agencies involved in checks. For children and supporting the person. young people the health checks will be incorporated into the education health and care plans in line with SEND requirements. Providers should clearly Locally the learning Quality visits to inpatient identify people requiring disability provider has areas includes questioning the provision of developed a ‘Learning around staff understanding reasonable adjustments, Disability Bundle’ which and application of record the reasonable incorporates a reasonable reasonable adjustments to adjustments that are adjustment care plan to ensure the core standards required and regularly enable staff to give are embedded. audit their provision. consideration to these Learning from LeDeR within the acute hospital reviews specific to setting. The learning reasonable adjustments disability provider offers will be shared with the support, expertise and Steering Group to drive guidance to care providers service improvement in making reasonable across the whole sector. adjustments to improve quality and safety of care for our patients. Mandatory Learning The NHS Long Term Plan Standards will promote

Disability awareness sets out that over the next greater consistency training should be five years, national addressing themes such provided to all staff, learning disability as rights, the workforce, delivered in conjunction improvement standards specialist care and with people with learning will be implemented and working more effectively disabilities and their will apply to all services with people and their families. funded by the NHS. This families. has been escalated to the Commissioner for Learning Disability and Mental Health Service. There should be a national Locally the learning Continuous improvement focus on pneumonia and disability provider has in better identification of sepsis in people with developed a “Stop & the deteriorating patient learning disabilities to Watch” information easy which, in turn, will improve raise awareness about the read leaflet. This is healthcare delivery and prevention, identification accessible to all care outcomes. and early treatment. providers, families, primary and secondary care and promotes the early recognition and identification of the deteriorating patient. Acute settings have a sepsis pathway in place. Local intentions are to collate and review data in relation to the uptake of the flu vaccine within the learning disability population. Local services strengthen The CCG seeks Continuous improvement their governance in assurance in line with the of the delivery of the relation to adherence to NHS schedule 6 Contract healthcare for people with the MCA and provide Service Condition for tier learning disability due to training and audit of 1, 2 & 3 providers, that the individual healthcare compliance “on the provider has relevant professionals receiving ground” so that policies for MCA and training and education in professionals fully DoLS, that staff have the application of the appreciate the received training and MCA. requirements of the Act in audits are completed to relation to their own role. support compliance with this legislation. The acute hospital liaison nurses provide bespoke MCA training to medical staff, it is envisaged this will roll out to include all staff disciplines. A strategic approach is E-learning training has Nominated reviewers will

9 required nationally for the now been implemented. complete the e-learning training of those Reviewer forums are held training. conducting mortality locally to provide a robust The steering group will reviews or investigations, supportive and learning ensure that there is local with a core module about environment for all representation at national the principles of reviewers. tailored undertaking reviews or modules/conferences. investigations, and The LAC attends the additional tailored modules regional LAC meeting to for the different mortality share learning and themes review or investigation from completed reviews methodologies. and gain an understanding of what is happening across the midlands region. This is disseminated to the local steering group and shared with local reviewers.

Objectives and plans for 2020-2021

The NHS Operational Planning and Contracting Guidance 2019/20 (10yr plan) now includes four deliverables in relation to the LeDeR programme: Lincolnshire CCG aligns as follows to these.

1. CCGs are to be a member of Learning from Deaths report (LeDeR) steering group and have a named person with lead responsibility. LCCG Action: - Designate nurse for Safeguarding Adults Children & Looked after children is the named lead and retains strategic oversight of LeDeR with operational support from within the safeguarding team. There are formal links both locally and regionally to implementation and steering groups.

2. There is a robust CCG plan in place to ensure that LeDeR reviews are undertaken within 6 months of notification of death to local area. LCCG Action: - The CCG’s tracks all new notifications to ensure this expectation is achieved.

3. CCGs have systems in place to analyse and address the themes and recommendations from completed LeDeR reviews. LCCG Action: - The CCG’s contributes learning from reviews to the local Steering Group where themes are collated and then priorities set for service improvement.

4. An annual report is submitted to the appropriate board/committee for all statutory partners, demonstrating action taken and outcomes from LeDeR reviews. LCCG Action: - A number of reports have already been provided through internal governance arrangements. This is the first annual report provided by the CCG’s which will be shared in the same way and across partner agencies through the local safeguarding boards.

In addition to the actions above the Lincolnshire Steering Group have agreed the following local priorities:

5. The CCG’s to strengthen links with the Child Death Overview Panel to enable shared learning across the county in relation to Children’s Services, Generic Health services and Specialist Learning Disability Services.

6. To ensure robust oversight of quality and governance processes a sample of completed LeDeR reviews are scrutinised by the Steering Group. Bristol University no longer quality assures any of the LeDeR reviews captured in the programme website.

7. A non-recurrent lump sum has been awarded nationally to assist areas in addressing the ‘backlog’ of reviews. Lincolnshire does not have a backlog, however it has been recognised that areas should not be discounted and consequently have also been awarded these funds. It is proposed that Lincolnshire will:

a) Produce written information leaflets for families/carers incorporated in the Hospital/care home bereavement packs in relation to LeDeR. b) Engage with Experts by Experience to design a lanyard which identifies the practitioner as a reviewer to encourage conversations around the LeDeR process, acknowledge the reviewers contribution to the process and allow for identification by colleagues and relatives. c) To facilitate a development workshop for reviewers incorporating a carer’s story and subsequent involvement in the LeDeR process. Workshops to address issues and pertinent topics for reviewers such as MCA, BIA and parallel processes/CDOP. d) Explore the potential to develop specific quiet areas within organisations to improve experience for clients with Learning Disabilities and their relatives.

8. The CCG’s and local steering group will ensure that the learning from LeDeR is disseminated to health and social care services and care providers

including GP practices. Information will also be disseminated in the regular safeguarding newsletter.

Conclusion

1. The learning from the Lincolnshire LeDeR steering group echoes many areas that the National report has highlighted. The level of understanding and awareness about care and support for individuals with learning disabilities has improved. Over this year we have developed better partnerships which will facilitate joint learning and promote more coordinated care for individuals and contribute to service improvement.

2. Lincolnshire CCG continues to be committed to delivering the LeDeR programme. The past year has been challenging due to the initial backlog of reviews at the start of the year. Following significant engagement from all providers and commencement of the Safeguarding & Mortality Review nurse role, this has now been cleared and Lincolnshire is set to continue on its current trajectory.

3. Robust governance systems have been embedded to ensure the quality assurance process and share learning from the reviews across the system.

4. Acknowledgment has been given from NHS England that Lincolnshire is now in a favourable position compared to other areas across the Midlands region, Lincolnshire is rated as Green on the assurance matrix. As a result of the hard work and commitment of all involved in the LeDeR process across Lincolnshire we are now in a positive positon to consolidate learning into action and to progress into a more proactive approach to meeting the health needs of people with learning disabilities. Lincolnshire will be able to deliver targeted action and commitment to improve service delivery where required.