Governing Body
Meeting to be held at 2pm on Thursday 24th November 2016 in the Board Room, Sanger House, Brockworth, Gloucester GL3 4FE
No. Item Lead Recommendation 1 Apologies for Absence Chair
2 Declarations of Interest Chair
3 Minutes of the Meeting held on Chair Approval 29th September 2016 4 Matters Arising Chair
5 Patient’s Story – Supporting Helen Ford Information Children and Young People’s Emotional Health and Wellbeing 6 Public Questions Chair
7 Chair’s Update Chair Information
8 Accountable Officer’s Update Mary Hutton Information
9 Performance Report Cath Leech Information
10 Gloucestershire Sustainability Mary Hutton Information and Transformation Plan 11 2017/18 Planning Round update Ellen Rule Information
12 Social Prescribing Procurement Ellen Rule Approval
13 Out of Hours Procurement Mark Approval Walkingshaw 14 Constitution Update Alan Potter Approval
15 Standards of Business Conduct Alan Potter Approval Policy 16 Assurance Framework Cath Leech Information
Items to Note: 17 Integrated Governance and Julie Clatworthy Information Quality Committee Minutes 18 Primary Care Commissioning Alan Elkin Information Committee Minutes 19 Priorities Committee Minutes Chair Information
20 Joint Commissioning Mary Hutton Information Partnership Board Minutes 21 Any Other Business (AOB) Chair
Date and time of next meeting: Thursday 26th January 2017 at 2pm in Board Room at Sanger House
A recording will be made of this meeting to assist with the preparation of the minutes. This recording will be made on an encrypted device owned by the CCG and will be held securely for a maximum of one week before being deleted.
Governing Body
Minutes of the Meeting held at 2.00pm on Thursday 29th September 2016 in the Board Room, Sanger House, Gloucester GL3 4FE
Present: Dr Andy Seymour AS Clinical Chair Marion Andrews-Evans MAE Executive Nurse and Quality Lead Dr Charles Buckley CBu GP Liaison Lead – Stroud and Berkeley Vale Julie Clatworthy JC Registered Nurse Joanna Davies JD Lay Member – Patient and Public Engagement Alan Elkin AE Lay Member – Patient and Public Engagement and Vice Chair Helen Goodey HG Director of Locality Development and Primary Care Colin Greaves CG Lay Member - Governance Dr Malcolm Gerald MGe GP Liaison Lead – South Cotswolds Dr Will Haynes WH GP Liaison Lead – Gloucester Mary Hutton MH Accountable Officer Cath Leech CL Chief Finance Officer Dr Tristan Lench TL GP Liaison Lead – Forest of Dean Dr Hein Le Roux HLR Deputy Clinical Chair Ellen Rule (part meeting) ER Director of Transformation and Service Redesign Dr Raju Reddy RR Secondary Care Doctor Sarah Scott SS Director of Public Health, GCC Mark Walkingshaw MW Director of Commissioning Implementation and Deputy Accountable Officer In attendance: Helen Edwards (Item 5) HE Associate Director of Locality Development and Primary Care Stephen Rudd (Item 11) SR Head of Locality and Primary Care Development Hannah Williams (Item 14) HW End of Life Commissioning Manager/Quality Lead for Community Services Rachel Pearce RP Director of Commissioning Operations, NHS England Alan Potter AP Associate Director of Corporate Governance Fazila Tagari FT Corporate Governance Support Officer There were 5 members of the public present.
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1 Apologies for Absence
1.1 Appologies were received from Margaret Willcox.
2 Declarations of Interest
2.1 All GPs declared a general interest in: agenda Item 11 - Primary Care Strategy for Gloucestershire agenda item 12 - Sustainability and Transformation Plan Update; and agenda item 15 - Constitution Update.
3 Minutes of the Meeting held on Thursday 28th July 2016
3.1 The minutes of the meeting held on Thursday 28th July 2016 were approved.
4 Matters Arising
4.1 26.05.16 AI 12.4 - Performance Report – MW advised that the outcome of the SWASFT pilot was included within the performance scorecard and that the methodology underpinning this was outlined on pages 17-18 of the performance report (Agenda Item 12). Item Closed.
4.2 28.07.16 AI 9.15 – Performance Report – MAE advised that Becky Parish would be taking this action forward and would discuss the Patient Reported Outcome Measures (PROMs) with thhe Director of Patient Experience of GHFT.
5 Patient’s Story
5.1 HE presented a patient’s story relating to patients’ experiences of the social prescribing service.
5.2 HE provided a background context to the service and advised that as at the end of July 2016, 2264 referrals had been made through this scheme.
5.3 The Committee agreed that this was a welcome initiative which had received national recognition. MGe concurred and congratulated the
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CCG for its success.
5.4 RESOLUTION: The Governing Body noted the patient’s story.
6 Public Questions
6.1 There were no questions received from the public.
7 NHS England Priorities
7.1 RP introduced herself and provided a verbal update on the work of the NHS England and their key priorities.
7.2 It was noted that the NHS England South Central portfolio covered 14 CCGs, 31 prisons, 5 immigration centres and the armed forces amongst others.
7.3 RP explained the work that NHS England oversees i.e. direct commissioning, CCG assurance, screening and immunisations, primary care, complaints, quality improvement and safety.
7.4 RP advised that the key priorities for NHS England were:
sustainability of health services; delivery of the constitutional standards; cancer; mental health; maternity; national policies; and STP assurance process and supporting delivery.
7.5 RESOLUTION: The Governing Body noted the verbal update.
8 Gloucestershire Clinical Commissioning Group (CCG) Clinical Chair’s Report
8.1 AS presented this report that was taken as read and highlighted a summary of key issues that arose during August and September 2016.
8.2 AS updated members on primary care and advised that practices had organised themselves into 15 ‘clusters’ across the county. It
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was noted that the clusters were working on their bids for the STP funding and were now progressing with implementation.
8.3 Members noted the work being undertaken on the General Practice Forward View. It was noted that funding from NHS England had been received to support the General Practice Resilience Programme and the General Practice Development Programme.
8.4 AS drew attention to Section 4 of the report relating to the National GP Patient Survey and noted the positive results that had been achieved against the national average.
8.5 AS advised that the CCG recently submitted a sustainability self- assessment to the Good Corporate Citizen and noted that the CCG measured comparatively well compared to other CCGs in many areas.
8.6 Members were updated on the Gloucestershire living with and beyond Cancer Programme and were advised on some current delivery progress particularly within acute, community care and primary care.
8.7 AS updated members on the Mental Health work and advised that two of the elected members for Cheltenham in their roles as ‘Mental Health Champions’ had committed to delivering ‘Heads Up Cheltenham’ year of mental health action which would be launched on 10th October 2016 (World Mental Health Day).
8.8 AS advised that the Gloucestershire Suicide Prevention Partnership Forum had launched their five-year plan to reduce the rate of suicide in Gloucestershire which included raising awareness. AS advised that as part of this commitment, agencies recently supported the World Suicide Prevention Day on the 10th September 2016 by making pledges on social media using the hashtag #GlosCares. It was noted that councillors, local business leaders, staff and other dignitaries had participated in this initiative. SS highlighted the strong presence on social media and welcomed this initiative.
8.9 AS informed members that the CCG had commissioned 2gether and Swindon MIND to deliver a new 5 bedded house in Alexandra Road, Gloucester, for people aged 18 and upwards experiencing acute emotional distress associated with a mental health problem.
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The aim of the service would be to provide early intervention for those at risk of crisis, and prevent the need for admission to an inpatient setting by offering short term respite and wellbeing support.
8.10 Members noted that the CCG had funded the Crisis Café at Westgate Street to open every evening from 6pm – 11pm to offer non-clinical mental health support to people during out of hours. It was reported that since opening approximately six weeks ago, the project had received 250 visits/contacts and 40 separate individuals registered with the service. AS highlighted an example of an individual who was a high frequency user of the Emergency Department but had not attended since the café had opened.
8.11 RESOLUTION: The Governing Body noted the contents of this report.
9 Gloucestershire Clinical Commissioning Group Accountable Officer’s Report
9.1 The Accountable Officer introduced this report which was taken as read, and provided a summary of key issues arising during August and September 2016.
9.2 MH highlighted the work of the Transforming Care Programme and advised that capacity was being developed within the county to return long stay in-patients who were living around the county back to their home county to live in community based settings. It was noted that Gloucestershire had 16 such individuals placed in in- patient units.
9.3 MH informed members that an Integrated High Needs Team had been developed which incorporated social workers, clinical case managers, support planners and enablement workers. It was noted that the project had been a huge success.
9.4 Members noted that work was underway to improve the uptake of the Learning Disability Annual Health Checks as uptake was low.
9.5 It was noted that a £3.2m fund had been awarded for three years to assist vulnerable adults to re-join the workforce.
9.6 MH drew attention to Section 2.5 of the report relating to Positive
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Risk Taking and advised that this had been rolled out across the system with a multi-agency protocol being implemented. It was noted that this was an integral part of case management.
9.7 MH provided an update on the STP process and advised that there had been progress within the respiratory and dementia workstream. MH advised that a whole system approach was required for the outpatient follow ups which included offering alternative pathways to patients. MH advised that as part of the Medicines Optimisation Programme work, the CCG had taken an evidence based decision to stop prescribing Gluten Free and SIP Feeds in Gloucestershire. It was noted that an implementation plan would be developed in order to support this proposal. Members also noted the work being undertaken to maximise the community based care pathway by GCS in order to support the work of the integrated primary and community based urgent care services.
9.8 The work of the Cultural Commissioning programme was highlighted. MH felt that the programme had benefits of co- production and that steady progress was being made. It was noted that Gloucestershire was one of the pilot sites in England.
9.9 MH updated members on the prevention and self-care programme. It was noted that a plan had been developed which supported the STP and that the Prevention and Self-Care Board would be responsible for the overseeing the delivery of the Plan.
9.10 Members noted that following a period of engagement with staff, the CCG had launched its revised Vision and Values in May 2016.
9.11 RESOLUTION: The Governing Body noted the contents of this report.
10 Performance Report
10.1 CL presented the Performance Report which provided an overview of the CCG’s performance against the organisational objectives and national performance measures for the period to the end of August 2016.
10.2 The report was broken down into the five sections of the CCG Performance Framework as highlighted in Section 1. CL advised that a Lead Director had been assigned to respond to each area.
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Clinical Excellence 10.3 MW advised that the year to date performance for the 4 hour emergency department target was 87.3% which was above the STP trajectory. It was noted that good progress was being made to stabilise performance in the Emergency Department. MW advised that measures included promoting alternative pathways of care to patients and reducing the number of emergency admissions and in acute bed base capacity.
10.4 MW advised that lack of bed availability continued to be the main reason for breaches in 2016/17 and that further work with healthcare partners was being undertaken to reduce admissions was being undertaken i.e. GP in ED, rapid response and Ambulatory Emergency Care scheme.
10.5 MW advised that areas of good performance included the Referral to Treat (RTT) pathway and the 6 week diagnostic waiting times, and that performance had been maintained.
10.6 Members were advised that the Improving Access to Psychological Therapies (IAPT) performance was an area of concern. It was noted that there was strong performance against the recovery standard and there was a gradual improvement towards meeting the access target. MW advised that the CCG had increased its investments for this service to recruit additional therapists due to the level of concerns that had been raised.
10.7 Members were updated on the cancer performance target and noted that the delivery of cancer targets still continued to be a challenge. MW informed members of the mitigating work to address the issues in the cancer service, particularly focusing on the urology service. Key actions included operating a clinical assessment service provided by GP Care in order to manage capacity.
10.8 JC requested further clarity on the clinical governance arrangement MW for the GP Care Community Urology Service. MW advised that there was a key focus ensuring that robust governance arrangements were in place and suggested that this could be shared at the IGQC meeting.
Patient Experience 10.9 MAE updated members on the Friends and Family Test (FFT) for
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GHFT. MAE advised that GHFT had recently changed providers and were trialling different methodologies such as text messaging. It was noted that this had been successfully implemented within the Emergency Department with a good response rate and was being rolled out to other departments.
10.10 MAE advised that Patient Participation Groups (PPGs) had been established in approximately 90% of practices and that the CCG were liaising with the remaining practices to ensure that this was being addressed.
10.11 MAE informed members regarding the mixed sex breaches within GHFT and highlighted that the majority of these breaches occurred in the Acute Care Units (ACU). It was assured that the privacy and dignity had been protected for all these patients
10.12 Members noted the work being undertaken to raise awareness on sepsis and signpost clinicians to a set of resources. It was noted that a key resource included a National Early Warning Score (NEWS) which was being adopted across the wider system as a clinical decision making tool to help prioritise the urgency assigned to a patients care. MAE highlighted that as a result of this initiative, the CCG had been shortlisted for a Nursing Times Award in the Patient Safety Improvement category for tackling sepsis.
Partnerships 10.13 MW highlighted the strong partnership working and advised that the system resilience plan had been agreed for 2016/17 including a series of investments to improve system performance this winter.
Staff 10.14 MW provided a brief update on the Staff Perspective and advised that this was rated as green. It was noted that the staff sickness was slightly above target and that staff would be reminded of the sickness absence policy and the support that was available.
10.15 CG highlighted the slight increase in staff sickness levels and enquired if there had been any underlying issues. MW advised that there were no underlying themes and that sickness levels had been monitored closely. MAE highlighted that staff should not be working from home if they were sick.
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Finance and Efficiency 10.16 CL provided a brief summary of the 2016/17 financial performance and reported that the CCG was forecasting to deliver a surplus of £9.456m which was in line with plan although noting that there were risks identified within this position.
10.17 CL advised that there was significant over performance in emergency activity against contracted levels and noted that the Emergency Department attendances had increased in GHFT.
10.18 Members noted that there was considerable pressure on the prescribing budget particularly with the introduction of new drugs and devices.
10.19 CL advised that other key emerging pressures related to the Funded Nursing Care (FNC). CL reported that a 40% increase to the FNC rate was announced by the Department of Health which would be backdated to 1st April 2016. This represented a cost pressure of approximately £3.2m to the CCG for 2016/17.
10.20 Members noted that there was slippage in the QIPP programmes particularly within Urgent Care and Planned Care schemes and noted the risk and mitigating actions associated with the schemes i.e. GP in ED and Planned Care follow up programmes.
10.21 CL advised that financial risks were managed through a continuous review of budgets and proposed investments and the use of the CCG’s contingency reserve. It was noted that the budgets were being reviewed in order to identify any slippage.
10.22 CL updated members on the number of actions being undertaken to mitigate any risks which impact on the achievement of the financial plan.
10.23 CL highlighted that a financial 'reset' plan was announced by NHS Improvement and NHS England in an effort to help CCGs and providers operate within the resources available and considered that it was unlikely that any additional allocation would be received.
10.24 Members were informed that the prescribing growth for July 2016 had reduced. CL considered that this was due to the significant decrease in the Category M drug prices.
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10.25 RESOLUTION: The Governing Body: noted the performance against local and national targets and the actions taken to ensure that performance was at a high standard; noted the financial position as at month five; noted the risks identified in the Finance and Efficiency report; and noted progress on the QIPP schemes.
11 Primary Care Strategy for Gloucestershire
11.1 HG introduced the Primary Care Strategy for Gloucestershire and provided the background context to developing the strategy. The paper was taken as read.
11.2 SR advised that following delegated commissioning responsibility for Primary Care from NHS England in April 2015, the CCG’s Primary Care and Localities Team had been working hard with partners and stakeholders since early 2016 to develop a comprehensive Primary Care Strategy for the next five years. SR thanked everyone for their support and feedback in developing the Strategy.
11.3 SR advised that the timing of this work had been useful as it coincides with the production of the local Gloucestershire STP and the NHS England General Practice Forward View.
11.4 SR informed members that the consultation on the strategy had taken place with a number of stakeholders. A final round of engagement was undertaken during August 2016. It was noted that no material adjustments resulted from this exercise.
11.5 It was noted that all hyperlinks within the document would be made operational by the Graphics Team following final sign-off and would be available on the website.
11.6 SR advised that the primary care vision was initially developed from the feedback received at the countywide Primary Care Strategy event and subsequent locality events.
11.7 Members were advised that the primary care vision for Gloucestershire was:
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‘So patients in Gloucestershire can stay well for longer and receive joined-up out of hospital care wherever possible, we need to have a sustainable, safe and high quality primary care service, provided in modern premises that are fit for the future’.
in order to do this, the CCG would:
attract and retain the best staff through promoting Gloucestershire as a great place to live and work, and offering excellent training opportunities; ensure good access to primary care 7 days a week; create a better work-life balance for primary care staff; maximise the use of technology; reduce bureaucracy; and support practices to explore how they can work closer together to provide a greater range of services for larger numbers of patients.
11.8 SR advised that the six strategic components that would improve patient care were:
access; developing the workforce; primary care at scale; integration; greater use of technology; and estates.
11.9 It was noted that all elements of the Primary Care Strategy would be developed into clinical programme pathways which would be delivered through the Primary Care Operational Group and reported to the Primary Care Commissioning Committee.
11.10 SR advised that the Strategy presented was the full version and that work was underway to summarise this into a ‘Short Guide’ for a wider audience, including patients, primary care teams, staff within local providers, etc. It was noted that the short guide of this Strategy would be developed in conjunction with Healthwatch Gloucestershire with a view to publishing in October 2016.
11.11 The Governing Body commended the Primary Care Team for their hard work in producing the Strategy. JC felt that the buy-in from the
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stakeholders was also commendable.
11.12 MGe emphasised that the CCG role was to ensure that funding can be unlocked so that real change could be made and that existing services would need to be utilised in order to enable staff to work better and efficiently. CBu concurred and recognised the challenge in identifying existing resources.
11.13 HG advised that the delivery of the Strategy was vital highlighting that a programme timeline would be established with a view to report regularly to the PCCC and the Governing Body.
11.14 AS highlighted that primary care currently equated to 7.9% of the total budget costs and it was indicated by Simon Stevens that this should increase to 11% by 2020.
11.15 RESOLUTION: The Governing Body: approved the Primary Care Strategy; and commented on the proposed approach for the short version of the strategy and agreed that this can be signed-off by the PCCC.
12 Sustainability and Transformation Plan (STP) Update
12.1 MH presented the report which provided a further update from the July 2016 STP Governing Body paper. The report was taken as read.
12.2 MH advised that significant progress had been made towards developing the Gloucestershire STP and the transformation work programme sets out clear ambitions for radical improvement informed by national and local benchmarking.
12.3 MH advised that there was a requirement to align the annual planning cycle to the STP and achieve contract sign off by the earlier date of December 2016. It was noted that this was a change to the usual requirement to sign contracts and agree operating plans by the end of March 2017 and recognised that this was a significant challenge.
12.4 Members were informed that a communication and engagement strategy and plan had been developed to support the STP approach. It was noted that a community partner briefing had been
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developed to circulate to key stakeholders.
12.5 MH informed members that a Memorandum of Understanding (MOU) had been agreed by all organisations to support the delivery of STP across the system and invited feedback from members. The MOU outlined the approach of work together, confirming the approach of sharing risk, information sharing and governance and clinical governance to support integrated working.
12.6 MH updated members on the programme timetable and advised that a finance resubmission was made on the 16th September 2016 and that the STP resubmission should be made on the 21st October 2016. MH considered that there should be no significant changes in the direction of travel in the STP previously presented.
12.7 JC felt that the quality oversight was not coherent within the MOU and also queried the position of the strategic clinical view within the system. JC suggested that the clinical leaders should be utilised and was advised that quality was embedded within all of the processes and that any quality issues would be addressed through any change management process. ER also advised that the majority of the programme boards had senior clinical leadership representation at the boards.
12.8 CG drew attention to Section 11.2 of the MOU relating to intellectual property rights and suggested that legal advice was sought on this statement.
12.9 CG also highlighted that there was no reference to the arrangements for the partners and stakeholders within the source document of the MOU. ER advised that appendices would be added to the individual programme area outlining the detailed arrangements for projects. CG advised that it would be useful if this was referenced within the source document.
12.10 CBu highlighted section 3.2 of the MOU in relation to ‘we will not commission or provide services that are deemed by evidence to not be cost-effective or clinically effective’ and enquired if there would be an oversight group who would review this as the Clinical Effectiveness Group currently had this responsibility for the CCG. ER advised that this should be covered as part of the Reducing Clinical Variations Board role.
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12.11 CBu also queried how the role of the Responsible Clinician would ER be managed particularly in terms of the indemnity arrangements and sharing responsibility with primary care. ER agreed that she would clarify this and report back.
12.12 MGe queried if a brief charter of behaviour could be established ER describing the principles which partners must adhere to in order to fully understand their role. ER advised that a draft set of behavioural principles had been developed as part of the GSF work and agreed to share this.
12.13 RESOLUTION: The Governing Body noted the Gloucestershire STP progress update as of September 2016, with particular note of the changes to the national annual planning cycle described in section 2.2 of the paper; approved the MOU in principle subject to the comments raised; agreed to delegate authority to MH to sign off any minor changes.
13 Emergency Planning, Response and Resilience (EPRR) Annual Assurance 2016/17
13.1 MAE presented the report and advised that NHS England had introduced an EPRR Assurance Process in 2013 to ensure that the health community throughout the country can evidence a standard level of preparedness across a broad spectrum of Emergency Planning related matters. The assurance process required the CCG to undertake a self-assessment against the relevant core standards identifying the level of compliance with each. The CCG was required to report the results of the assessment following Governing Body approval.
13.2 MAE advised that the CCG were compliant with 29 of the 30 core standards. It was noted that the one remaining standard was that of Mutual Aid. It was noted that there were no clear definition of Mutual Aid and that further guidance from NHS England was still awaited.
13.3 MAE also advised that the CCG had been meeting with providers to review their annual self-assessment to ensure that they were compliant. It was noted that NHS England staff had also attended some of the meetings between the CCG and local NHS providers.
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This was to provide assurance to NHS England that the CCG was undertaking these processes appropriately.
13.4 Members were advised that there was a deep dive process that sought assurance around business continuity and fuel resilience. It was noted that all providers were challenged on this area and had been requested to undertake a deep dive process. MAE confirmed that all providers had participated in this process.
13.5 MAE advised that the assurance process would be discussed further at the CCG Quarter 2 assurance meeting with NHS England.
13.6 MAE advised that the following year, there would be a requirement for the CCG to seek assurance from all practices to ensure that they were compliant with the standards. It was noted that Andy Ewens, Emergency Planning and Business Continuity Officer, would be meeting with practice managers to support them further on this process.
13.7 AS queried if practices would have completed most of the work if they were already CQC compliant. MAE advised that the process was more comprehensive than the CQC process which included reviewing their business continuity plan in more detail.
13.8 CG commended Andy Ewens for the work he had completed on the Business Continuity and Emergency Planning. MAE concurred and advised that Andy had arranged for all the emergency planning officers within the county to undertake an extensive training programme and examination in managing business continuity. It was noted that all candidates had passed this exam.
13.9 MAE highlighted the strong partnership working between organisations and highlighted that there was a robust system wide resilience plan in place. SS concurred and advised that there was a marked improvement.
13.10 RESOLUTION: The Governing Body: signed off the CCG self-assessment for 2016; accepted the level of preparedness of the CCG; and noted that the final assessment of the CCG’s emergency preparedness would be submitted to NHS England.
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14 Gloucestershire End of Life Strategy
14.1 MAE introduced the Gloucestershire End of Life Strategy and provided a background context. The report was taken as read.
14.2 It was noted that the Strategy had been presented to the Gloucestershire Health and Wellbeing Board on the 20th September 2016.
14.3 HW advised that the Strategy should align with the national and local policy context including the ‘Ambitions Framework for Palliative and End of Life Care’ (published in 2015).
14.4 HW considered that Gloucestershire was ahead of the game particularly compared to other areas as not everyone had considered shaping their future direction of travel in terms of responding to the ambitions framework.
14.5 HW advised that the six ambitions for Gloucestershire were:
each person was seen as an individual; each person gets fair access to care; maximising comfort and wellbeing; care was coordinated; all staff were prepared to care; and each community was prepared to help.
14.6 HW advised that there were twelve strategic aims for Gloucestershire which built upon the CCGs commitment to improving end of life care. These were outlined in the Strategy.
14.7 HW advised that in order to deliver against the 12 strategic aims, it had been agreed that there were a number of priority work-streams that needed to be established. Each work stream would develop a measurable action plan and would be supported by a multi- stakeholder implementation group that would drive this work forward.
14.8 JC highlighted that Appendix C of the Strategy should read as ‘Quality Standard’.
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14.9 MGe enquired if some of the key issues could be prioritised and was advised that the workstreams established were identified as key priority areas i.e. treatment escalation plans and noted that the details would be included within the workstream action plan.
14.10 RESOLUTION: The Governing Body endorsed the End of Life Strategy.
15 Revision of the GCCG Constitution
15.1 AP presented the document and advised that the document had been reviewed to ensure that it remained relevant and suitable for the organization and in accordance with the advice received from NHS England to reduce the size of the Constitution, a number of documents that were previously appended had now been extracted and collected into a supporting documents volume ‘Supporting Documents to the Constitution’.
15.2 AP advised that all changes made, other than minor typographical corrections, were shown by way of ‘tracked changes’ in both documents.
15.3 AP advised that the principle changes related to: member practices changes; adding text regarding the engagement strategy on page 44; conflicts of interests process following the NHS England guidance; standards of business conduct; and appointment process for the Clinical Chair and the Deputy Clinical Chair.
15.4 AS advised that a small working group was established to review the Constitution ensuring that it reflected the work of the CCG.
15.5 AS highlighted Section 2.2.2 of the Constitution regarding the Clinical Chair and Deputy Clinical Chair of the Governing Body and proposed that the eligibility for this role should be broadened to being a GP on the Gloucestershire Performers List and that this also should apply to all GPs on the Governing Body.
15.6 MGe highlighted that the CCG was a membership organisation and AS felt that the CCG GPs should be from a member practice. The Governing Body debated if this should be a GP representative or a Gloucestershire CCG Governing Body Minutes – September 2016 Page 17 of 19
practice representative. AS agreed to discuss this issue with GPs.
15.7 The Governing Body agreed that this would be discussed further and agreed to defer the approval of the Constitution to the November meeting.
15.8 RESOLUTION: The Governing Body deferred the decision.
16 Assurance Framework
16.1 CL presented the Assurance Framework for 2016/17 which was taken as read. The Assurance Framework identified gaps in assurances and controls regarding the organisational objectives, along with details of the principal risks that have been identified by lead managers.
16.2 CL informed members that only high level risks with a rating above 12 were included within the Assurance Framework in order to provide focused discussions.
16.3 CL highlighted that the key issues related to: risk No T13 regarding the specialised services for children and young people with mental health problems; and risk No C5 regarding discharge
16.4 RESOLUTION: The Governing Body noted the paper and the attached Assurance Framework.
17 Integrated Governance and Quality Committee Minutes
17.1 The Governing Body received the minutes of the meeting of the Integrated Governance and Quality Committee held on the 23rd June 2016.
17.2 RESOLUTION: The Governing Body noted these minutes.
18 Audit Committee Minutes
18.1 The Governing Body received the minutes of the meeting of the Audit Committee held on the 12th July 2016.
18.2 RESOLUTION: The Governing Body noted these minutes.
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19 Primary Care Commissioning Committee Minutes
19.1 The Governing Body received the minutes of the meeting of the Primary Care Commissioning Committee held on the 26th May 2016.
19.2 RESOLUTION: The Governing Body noted these minutes.
20 Any Other Business
20.1 There were no items of any other business.
21 The meeting closed at 16:05.
22 Date and Time of next meeting: Thursday 24th November 2016 at 2pm in the Board Room at Sanger House.
Minutes Approved by Gloucestershire Clinical Commissioning Group Governing Body:
Signed (Chair):______Date:______
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Agenda Item 4
Matters arising from previous Governing Body Meetings – September 2016
Ittem Description Response Action with 28.07.2016 Performance RR understood that surgeons felt that the PROMs were MAE Agenda Item Report reported on prematurely in order to judge any true 9.15 outcome measures and enquired if this could reported further down the line. MAE advised that the national response period was 6 months and agreed that a local benchmark should be established. MAE agreed to discuss. 29/09/16 Becky Parish to discuss this with the Director of Patient Experience of GHFT. 29.09.2016 Performance JC requested further clarity on the clinical governance MW Agenda Item Report arrangement for the GP Care Community Urology Service. 10.8 MW advised that there was a key focus ensuring that robust governance arrangements were in place and suggested that this could be shared at the IGQC meeting. 29.09.2016 Sustainability and CBu also queried how the role of the Responsible Clinician ER Agenda Item Transformation would be managed particularly in terms of the indemnity 12.11 Plan (STP) Update arrangements and sharing responsibility with primary care. ER agreed that she would clarify this and report back. 29.09.2016 Sustainability and MGe queried if a brief charter of behaviour could be ER Agenda Item Transformation established describing the principles which partners must 12.12 Plan (STP) Update adhere to in order to fully understand their role. ER advised that a draft set of behavioural principles had been developed as part of the GSF work and agreed to share this.
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Agenda Item 4
29.09.2016 Revision of the MGe highlighted that the CCG was a membership AS Agenda Item GCCG Constitution organisation and felt that the CCG GPs should be from a 15.6 member practice. The Governing Body debated if this should be a GP representative or a practice representative. AS agreed to discuss this issue with GPs.
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Agenda Item 7
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Gloucestershire Clinical Commissioning Group Clinical Chairs Report Executive Summary This report provides a summary of key update and issues arising during October and November 2016. Key Issues The key issues arising include:
Primary Care Update; County-wide event for Care Home and Domiciliary Care staff; Dementia Update; Clinical Programmes Update; and Meetings attended Risk Issues: None. Original Risk Residual Risk Financial Impact None. Legal Issues (including None. NHS Constitution) Impact on Health None. Inequalities Impact on Equality and None. Diversity Impact on Sustainable None. Development Patient and Public Not applicable. Involvement Recommendation The Governing Body is requested to note this report which is provided for information. Author Dr Andrew Seymour Designation Gloucestershire CCG Clinical Chair Sponsoring Director (if not author)
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Gloucestershire Clinical Commissioning (GCCG) Clinical Chairs Report
1 Introduction
1.1 This report provides a summary of key updates and issues arising during October and November 2016.
2 Primary Care Update
2.1 Since the previous report, our Primary Care Strategy was presented to and approved by Governing Body. Presentations on the Primary Care Strategy, the GP Forward View (GPFV) and the CCG’s response have been given to Locality Executive Groups and to GP Provider Leads. A programme plan covering the Strategy and GPFV is now being developed. A patient version of the Strategy has been drafted with the support of Healthwatch Gloucestershire with the intention of publication in November.
2.2 Since the last report, NHS England has announced further detail on the implementation of the GPFV including the need to submit GPFV plans by 23rd December 2016. The other two key requirements are Improving access and Practice transformational support. Our CCG has already made a positive start in respect of Practice transformational support having committing funds on a recurrent basis and our Practices have already formed into clusters to bid for these funds. We now have 16 clusters across the county. The 14 bids from the clusters covering clinical pharmacist, repeat prescribing, urgent care, mental health in primary care and a frailty service are all being progressed.
2.3 To support sustainable primary care, funding will also be distributed to clusters for staff training in active signposting and correspondence management. A Memorandum of Understanding has been developed for this purpose and will be shared with clusters by the end of October. Additional NHS England funding for online systems and practice manager development are expected.
2.4 The roll out of our work on a Place based model which commenced in Stroud and Berkeley Vale continues. Gloucester City practices have defined their clusters and are in the process of nominating lead GPs.
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An initial Project Board meeting for all Gloucester City clusters together with other provider organisations is planned for November. Work on Place in the four Stroud and Berkeley Vale clusters, North Cotswold and Tewkesbury, Newent and Staunton continues positively. A number of the GP Provider Leads attended a visit to Dudley CCG in September to understand their Multispecialty Community Provider (MCP) Vanguard model, the procurement process underway and their journey so far. This has provided valuable learning of how providers are working together to deliver care differently in advance of any actual contractual change. A visit to Modality in Birmingham is planned for mid-November.
2.5 In terms of improving access, the CCG is leading a project to design and agree a service model to deliver integrated primary and community based urgent care services seven days per week across Gloucestershire with agreed plans that can be commissioned and implemented from the Spring of 2017 onwards. Workshops with a range of stakeholders were held over the summer and the programme of work is now being taken forward in detail across three broad themes/tiers, with the aim of producing a business case by the end of November.
3 County-wide event for Care Home and Domiciliary Care staff
3.1 On 21st October 2016, the CCG Quality Team hosted the 'Hot Topics in Health Care' event at Cheltenham Racecourse. This event had been marketed particularly at health and care staff working within community settings including residential care and nursing homes, agency nurses and domiciliary care staff. The event was well supported with 228 delegates attending on the day.
3.2 Presentations were delivered in short, informative sessions throughout day covering topics such as Flu Myth Busting, Infection Control, Dementia Training and Education, End of Life Strategy and Social Prescription. All the presenters were drawn from Gloucestershire service providers. The day was part of the Continuing Professional Development requirements of the NMC revalidation process.
3.3 In addition to the above, a market place area was available for delegates to browse and access information from a range of stands. Exhibitors in this area included Royal College of Nursing,
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Gloucestershire County Council, University of Gloucestershire, Integrated Community Equipment Service and Warm & Well at Severn Wye Energy Agency, along with information stands from within the CCG including End of Life resources and Tackling Mental Health Stigma.
3.4 Initial feedback from the event has been extremely positive from both attendees and exhibitors. A review of the event will be held by the Quality Team and it is hoped that this can be established as a regular annual event ensuring that consistent messages regarding Gloucestershire care pathways, initiatives and wider health-related clinical developments can be cascaded to these key staff groups working across the Gloucestershire community.
4 Dementia Update
4.1 The Dementia Clinical Programme Group has been set up, with the initial Dementia Partnership Board meeting in September 2016. Development of the CPG has been in close collaboration with the 2gether NHSFT Chair and project support to ensure that:
all aspects of the Gloucestershire Dementia Strategy work are included, particularly non-clinical initiatives; service redesign proposed by internal 2gether NHSFT and review by Dementia Strategy are aligned; NHSE targets such as Dementia Diagnosis Rates remain a priority, as well as any additional metrics for 2017/18; and There is consistency with CCG Clinical programme methodology.
5 Clinical Programmes Update
5.1 We are pleased to report the following developments within our Clinical Programmes:
5.2 Respiratory
5.2.1 The Chronic Obstructive Pulmonary Disease (COPD) pathway has been reviewed, with an integrated approach to delivery now being developed under the umbrella of the STP. A scheme for identified respiratory patients, focusing on COPD, to receive an additional primary care review has been offered across Gloucestershire
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practices; proving additional support to identified patients through the winter months. In addition an approach to a discharge care bundle across the system is under consideration.
5.3 Circulatory
Cardiology The waiting list for elective Angiograms was successfully cleared in May 2016. There has been a significant amount of work for chest pain pathways and this has resulted in a steady reduction in urgent admissions for chest pain (based on the 4 month period June 2016 to September 2016), with a noted reduction in patients attending Emergency Department (ED) then requiring admission. The use of the Ambulatory Emergency Care (AEC) unit has remained constant, and there has been no increased effect on Length of Stay which has remained under 2 days.
The arrhythmia and heart failure services have a number of opportunities being agreed through the CPG, which will improve access and quality for these patients.
Stroke Following the Circulatory CPG in September a number of key areas for performance improvement have been identified including: improving Thrombolysis rates and increasing access to TIA clinics. A number of actions to achieve this include: increasing stroke specialist nurse availability; establishing an ED consultant as lead for stroke care within the ED, internally discussing an approach for the provision 7 day TIA clinics and development of a number of internal business cases for improved staffing. In addition, the CPG continue to explore the community bed model for stroke patents.
5.4 Eye Health
5.4.1 The community eye care service is in place, with provision including Glaucoma referral enhanced case finding and repeat readings, Cataract second eye follow up and minor eye conditions. There are 67 sub-contractor practices signed up, providing good geographical coverage across the county, with 98 practitioners fully trained. Regular monthly performance meetings are now in place to monitor performance against agreed contracted activity. The Primary Eye Care
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Company and GHFT are now working collaboratively working on next phase protocols for School Vision Screening in preparation for go-live in 2017.
5.5 MSK
5.5.1 The MSK programme has introduced Multi-Disciplinary Team (MDT) and Clinical Network Group forums, focused on streamlining internal service process and introduced informal triage as part of its work programme. In support of these improvements a number of pathways are being developed for sharing across primary care clinicians via G- care.
5.6 Diabetes
5.6.1 The Type 2 diabetes workshop took place in September this year. It welcomed a wide range of stakeholders, including generalist and specialist clinicians; managers and patient representatives, to discuss the patient journey from diagnosis through to referral to complication management. The discussions led to a series of recommendations which are now being prioritised and acted upon. A second workshop which will focus on Type 1 diabetes (children and adults) is planned for November 3rd.
5.6.2 As part of the AHSN Diabetes Digital Coach programme, the Mapmydiabetes project, which is enabling patients in Gloucester City and Forest of Dean to access online, NICE approved, diabetes structured education and self-management resources, is well underway. Ten (out of a total of 11) practices in the Forest of Dean have at least one member of staff trained and using the system. Five practices in Gloucester City are up and running and dates have been set in early November further training. We already have 100 patients with accounts set up by practices and over half of those have been actively accessed. The learning form these localities will inform a proposal to extend provision across rest of the county.
5.6.3 In the second AHSN Diabetes Digital coach initiative, GCCG, Hucclecote surgery and Ki Performance are piloting a remote monitoring physical activity programme for patients with type 2 diabetes. The project will be recruiting 200 patients over the next 12 months and will involve patients monitoring their activity levels to help
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them manage their diabetes. Patients will undertake a 12-week evidence-based digital behaviour change programme supported by a personal coach.
5.7 Cancer
5.7.1 Our extensive programme is delivering improvement in health outcome to the people in Gloucestershire affected by cancer in line with the national strategy to achieving World-Class Cancer Outcomes: a cancer strategy for England 2015-16. We continue to build our partnerships within the county and beyond and in October became members of the Somerset, Wiltshire, Avon and Gloucestershire Cancer Alliance.
Early Diagnosis of Cancer 5.7.2 This autumn we have launched our third series of Macmillan GP Master Classes, with events on Prostate Cancer in September and Lung Cancer in October. We have now achieved over 1000 attendances by Gloucestershire GPs at these interactive educational events that are raising clinical knowledge on the early signs of suspected and awareness of the referral, diagnosis and treatment pathways. This has been complemented by a major project across all cancer sites to implement the latest NICE guidelines NG12, this is now delivering new referral forms, G-care GP guidance and proposals to develop diagnostic pathways to ensure as many cancers as possible are detected at an early stage. Further programme plans are now in development to further advance our working including working in closer collaboration with screening programmes and to developed targeted public awareness work for high risk population groups
Gloucestershire Living With and Beyond Cancer Programme 5.7.3 This wide-reaching programme encompasses a number of priorities transforming patient care with a range of partners across the care pathway, focussing in the current phase on Breast, Prostate and Colorectal Cancer. Within the hospital, GHNHSFT have started to implement the Cancer Recovery Package of Holistic Needs Assessments (HNA) and Care Plans. Progress is now accelerating with a new Macmillan Nurse Lead commencing in post, and recruitment has now been completed for 4 Support Workers to assist in the successful implementation with specific teams (Breast, Colorectal, Prostate and Oncology). Plans are in place to implement e-HNA assessment using hand held tablets to improve access to more
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patients and spread to other cancer specialities.
5.7.4 The service design work is now well progressed for shifting to a needs based follow-up approach and the production of Treatment Summaries to improve communications with patients and between health partners. Our innovative community-based project Macmillan Next Steps Cancer Rehabilitation is progressing well with all strands now successfully tested as part of the pilot, including a range of patient education programmes, 1:1 specialist recovery care including physiotherapy, occupational therapy, dietetics and emotional support. The ethos is to encourage health lifestyles and to enable patients to successfully self- manage. Finally in Primary Care we are pleased to announce the launch of our Practice Nurse education programme, with a number of days available across the county during November this learning day builds our capacity to support people living with cancer in the community.
6 Meetings
11th October – Health & Social Care Awards Judging Panel, Cheltenham 11th October – Provider AGM, Gloucester 13th October – Gloucestershire STP & WEAHSN Annual Conference, Swindon 20th October – GSF Five Year Forward View Workshop, Cheltenham 21st October - Attendance at the official opening of Park View Care Home, Gloucester 27th October – Leadership Gloucestershire, Gloucester 1st November – NMOC Board Meeting, Gloucester 3rd November – NHSCC Members Event, London 8th November – Gloucestershire Health & Social Awards, Gloucester 10th November – CCG Lay Member Interviews, Gloucester 10th November – LMC, Gloucester 21st November – Director of Integration Interviews, Gloucester 29th November – Health & Wellbeing Board, Gloucester
7 Recommendations
This report is provided for information and the Governing Body is requested to note the contents.
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Governing Body Agenda Item 8
Governing Body Thursday 24th November 2016 Meeting Date Title Gloucestershire Clinical Commissioning Group Accountable Officer’s Report Executive Summary This report provides a summary of key update and issues arising during October and November 2016. Key Issues The key issues arising include:
ICT Rapid Response Pathway; Patient Activation Measures; Workplace Wellbeing Charter; Cultural Commissioning; Facts4Life; and Meetings attended Risk Issues: None. Original Risk Residual Risk Financial Impact None. Legal Issues (including None. NHS Constitution) Impact on Health None. Inequalities Impact on Equality and None. Diversity Impact on Sustainable None. Development Patient and Public Not applicable. Involvement Recommendation The Governing Body is requested to note this report which is provided for information. Author Mary Hutton Designation Gloucestershire CCG Accountable Officer Sponsoring Director (if not author)
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Gloucestershire Clinical Commissioning (GCCG) Accountable Officer’s Report
1. Introduction
1.1 This report provides a summary of key updates and issues arising during October and November 2016.
2. ICT Rapid Response Pathway
2.1 This report provides a summary of progress of the development of the ICT Rapid Response pathway for Care Homes in avoiding hospital admissions.
2.2 Pilot - Phase 1
Initial exploratory work to develop a model where nursing home nurses could contact Rapid Response direct took place from October 2015.
Early indications of positive outcomes from case study data included:
avoidance of hospital admissions; reduced length of stay for those who were admitted; need for frequent GP visits was reduced; improved care planning; improved relationships between clinicians and care home staff; improved patient experience; and increased care home staff confidence and expertise due to local training and support including re NEWS (National Early Warning Score) together with the Care Home Support Team (CHST).
Initial outcomes provided sufficient evidence to extend the pilot to further test and develop the model.
2.3 Pilot – Phase 2
A further three nursing homes were selected to give a range in terms of size, geographical area, emergency hospital admission and approach to End of Life Care. Link workers were identified in each home. Work commenced May 2016 and is on-going.
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Monitoring of Phase 2 data including review of hospital admissions and case studies reinforced the outcomes initially identified above resulting in the development of more formal KPIs including:
reduction of avoidable emergency hospital attendances and admissions; increase in referrals to Rapid Response for Nursing Home patients; and quality improvements in patient experience and patient flow.
2.4 Work continues to :
further develop Key Performance Indicators (KPIs); increase the number of participating care homes; and establish the evidence base to consider options moving forward.
3. Patient Activation Measures (PAM)
3.1 Work is ongoing to embed the patient activation measure across the county. Three initial areas have been identified to operationalise and test the PAM tool within new models of care:
Frailty project in South Cotswolds; Winter Pressures Chronic Obstructive Pulmonary Disease (COPD) Local Enhanced Service; and Macmillan Next Steps Programme;
3.2 Patient Activation is a central ambition for the NHS Five Year Forward View and Gloucestershire’s Sustainability and Transformation Plan. Patient activation is a measure of a person's skills, confidence and knowledge to manage their own health. The objective of measuring patient activation is to enable a wider system shift towards self-care and person-centred care, particularly for patients with long term conditions. Evidence suggests that measuring individuals’ level of knowledge, skills and confidence, and then tailoring support through interventions that improve their activation, helps to empower patients and enables them to be in control of their own health and care
3.3 It has been demonstrated that activation levels are changeable. With effective support, individuals can increase their level of activation over time. Research also shows that increased health activation can lead to
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to improved self-care behaviours, better health outcomes, and more efficient use of health care services.
4. Workplace Wellbeing Charter
4.1 The charter has been positively received across the county. 15 businesses are now working toward accreditation. Nearly all public sector bodies (Local authorities, NHS and Police, fire and rescue (are either working to accreditation or have expressed an interest in the charter. The aim is to have 40 organisations accredited by June 2017.
5. Cultural Commissioning
5.1 The local grant programme is continuing to engage individuals and communities from all ages. One project involves working with young people with Type 1 Diabetes to make a dance and film based project to increase confidence and diabetes self-management. Our work continues to generate interest from across the country. We have been invited to talk at the regional Arts and Health South West Annual Conference. We are also continuing to participate and give evidence at the All Party Parliamentary Group on Arts, Health and Wellbeing.
6. Facts4Life
6.1 We are continuing to roll out Facts4Life across the county with 76 schools now having received training (target 96). Facts4Life is an innovative health education programme that aims to support children and their families to self-care. The initiative is currently being independently evaluated by the University of the West of England.
7. Meetings
05 Oct Joint Commissioning Partnership Executive (JCPE) 10 Oct Lilian Faithfull Homes 10 Oct Quarter 2 Assurance Meeting, Chippenham 12 Oct Enabling Activities Communities Commissioning Group 13 Oct West of England AHSN Annual Conference 2016, Swindon 17 Oct Whole Systems Obesity Workshop, Leeds 19 Oct Professor Prowle Feedback, Shire Hall 20 Oct NHSCC Board Day, London
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27 Oct Leadership Gloucestershire, Shire Hall 27 Oct Healthwatch Board 01 Nov New Models of Care Board 03 Nov NHSCC Member's Event, London 09 Nov Joint Commissioning Partnership Board (JCPB) 09 Nov Joint Commissioning Partnership Executive (JCPE) 10 Nov Lay Members Interview 15 Nov Health & Care Scrutiny Committee (HCSC) 21 Nov Director of Integration Interview 22 Nov Gloucestershire Strategic Forum (GSF)
8. Recommendations
This report is provided for information and the Governing Body is requested to note the contents.
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Governing Body Agenda Item 9
Governing Body Thursday 24th November 2016 Meeting Date Title Performance Report
Executive Summary This performance framework report provides an overview of Gloucestershire CCG performance against organisational objectives and national performance measures for the period to the end of October 2016. Key Issues These are set out in the executive summary within the report. Risk Issues: All risks are identified within the relevant sections Original Risk of this report. Residual Risk Management of None declared. Conflicts of Interest Financial Impact This report gives detail on the financial position to the end of October. Legal Issues These are set out in the main body of the report. (including NHS Constitution) Impact on Health Not applicable. Inequalities Impact on Equality There are no direct health and equality and Diversity implications contained within this report.
Impact on Sustainable There are no direct sustainability implications Development contained within this report.
Patient and Public These are set out in the main body of the report. Involvement Recommendation The Governing Body is asked to: note the performance against local and national targets and the actions taken to remedy the current performance position. note the financial position as at month 7.
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note the risks identified in the Finance and Efficiency report; and note progress on the QIPP schemes. Author & Designation Sarah Hammond, Head of Information and Performance Andrew Beard, Deputy CFO Ian Goodall, Associate Director of Strategic Planning Sponsoring Director Cath Leech (if not author) Chief Finance Officer
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Gloucestershire CCG
Performance Report
1.0 Executive summary
1.1 Introduction The performance report is broken down into the five sections of the GCCG performance framework: • Clinical Excellence • Finance and Efficiency • Patient Experience • Partnerships • Staff
A full summary of performance against all national and local standards is included within the relevant scorecard for that section of the report. An overarching GCCG performance dashboard is included as a supporting appendix; providing an overview of all key national and local targets. A further supporting appendix is provided in relation to the update on 2016/17 budgets.
Whilst inevitably this report focuses on areas of concern it should be noted that Gloucestershire is currently achieving the majority of the local and national performance standards.
1.2 Balanced scorecard 2016/17 – up to 30th September 2016
Overall rating Ref. CCG Internal Perspective Green
P1 Clinical excellence Amber
P2 Patient Experience Green
P3 Green Partnerships
P4 Green Staff
P5 Finance & Efficiency Amber
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Clinical Excellence – Amber,
Clinical excellence - Perspective highlights:
Progress is being reported across all active clinical programme groups
with good clinical engagement across the system
The Primary Care Clinical Quality Review Group have established a quality assurance framework for primary care. The group has met on several occasions and has considered the outcomes of practice Care Quality Commission (CQC) inspections. It is also monitoring 2016/17 seasonal flu vaccination performance,, medicines optimisation, QOF and primary care staffing including training and recruitment. Patient experience including the progress with patient participation groups and Friends and Family test (FFT) was also an agenda item.
Improvement and Assessment Framework (IAF) indicators show 3 Performing well & 3 Needs Improvement
Good performance: ED Performance year to date was 87.4%, which is 0.9% above the STP trajectory.
Challenging performance:
Delivery of cancer targets continues to be challenging.
62 days cancer is below STP trajectory at 78.1% for September and 78.4 % YTD
2 week cancer wait performance 88.4% (target 93%) YTD 86.6%
6 week Diagnostic target – September performance 2.5% (target 1%)
IAPT – the impact of the recent NHSE Intensive Support Team has resulted in improved compliance with IAPT recovery standard; however access rates have dropped following the decision to not count the nursing element of the service. IAPT access is currently 3.72% against a target of 7.5%
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Patient experience – Green.
Patient Experience - Perspective highlights:
The Practice Participation (PPG) Group network held a successful meeting in October 2016. The meeting focussed on reducing stigma in mental health, patient facing website and social prescribing and working with the community and voluntary sector. In response to requests from PPG members, two workshops have been arranged, facilitated by PPG members themselves, on the topics of ‘Developing your PPG’ and ‘Using online forums’.
Patient Engagement and Experience continues to develop across a wide range of GCCG projects – a particular recent focus has been Renal, Respiratory and Diabetes.
A wide range of engagement activity to support GCCG projects. In particular over 100 semi-structured interviews with renal dialysis patients in three units across Gloucestershire.
Good performance Challenging performance:
Comprehensive experience FFT - Results remain amber overall and engagement activity due to a Red rating for response supporting CCG work rate for the Inpatient FFT. However, programme. results are green for ED response Most GP practices in Gloucestershire now have a rate and %recommend for both ED Patient Participation Group and Inpatients. This is a marked (PPG). improvement. GP Patient Survey, (July 2016 publication) CCG GHFT have been requested to
average satisfaction with GP undertake focused work on patient services remains above experience for people using urgent national average. care services in the Trust as this has not previously been systematically monitored.
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Partnerships – Green rating with all indicators on target for achievement.
Partnerships - Perspective highlights: Gloucestershire is working to a local footprint for the development and implementation of the Sustainability and Transformation Plan. Our system submitted a second draft of our STP on 21st October 2016 to NHS England and published our plan and accompanying short guide and survey on 11/11/2016. A communication and engagement plan has been developed to support the STP approach, to ensure comprehensive and planned engagement and communication with the public and key stakeholders. The plan takes a two phase approach; with Phase One covering our new models of care and new ways of working from autumn 2016 to spring 2017 and Phase Two covering more detailed proposals for service change to commence during the summer 2017.
A system resilience plan has been agreed for 2016/17 including a series of investments to improve system performance this winter.
Discharge summit – A summit has taken place attended by key operational teams, CEOs and lead Directors to agree a number of system wide actions necessary in order to address the current pressures on the urgent and emergency care system (with a particular emphasis upon addressing potential barriers to timely discharge from hospital).
Staff – Green.
Staff - Perspective highlights:
Staff sickness level for October is 2.49% against a target of 3%.
A working group is progressing the organisational development plan and will complete a refresh for 2016/17.
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Finance and efficiency – Amber
Finance and Efficiency - Perspective highlights:
The overall assessment for the finance and efficiency perspective against the NHS England criteria is amber. The CCG is forecasting to deliver a surplus of £9.456m, however, there are significant risks to achieving this position
Achievement of the forecast position depends on delivery of a number of additional in year schemes for urgent care, prescribing and follow up outpatients
Good performance Challenging performance:
Activity at GHNHSFT continues The CCG is forecasting to deliver a surplus of £9.456m to over perform against planned levels although several The better payment practice challenges are being code performance for the year progressed. to date (for non-NHS invoices by value) is 98.52% which is Activity in other Trusts is also above the target figure of 95%. showing significant pressures, primarily Great Western and Winfield.
QIPP schemes for 16/17 total
£18.042m. Currently reporting
slippage of £3.11m.
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1.3 GCCG Performance Framework Overview
The sections below provide an overview of each domain. Each of the sections is broken down into success criteria which when combined provide an overall rating for the domain. The development of the partnerships section is ongoing as this is an area of development for the CCG.
All indicators are RAG rated, based on the 2016/17 NHS England planning thresholds. Key national and local indicators are given an overall rating by weighting their importance to the organisation. Indicators which feature in the NHS constitution, Quality Premium and CCG assurance framework receive the highest weighting with local targets being given a lesser value. The overall rating is then derived from the combined score of those targets rated Amber and Red.
Areas of performance assessed as being at risk of failure at year end, or other issues that engender concerns throughout the year, for which the Governing Body need to be made aware of, are reported upon within this report. Where standards are reported on a quarterly basis, the Governing Body will be informed of updates as and when data is available or new information comes to light.
Performance framework
The GCCG performance framework measures the in-year success of the organisation by linking the key organisational objectives to perspectives. Each of the five perspectives is given a Red, Amber or Green rating based on the progress made against a number of locally defined critical success criteria.
Key local and national commissioned performance targets are also reported under each domain; however, the overall rating of each perspective is derived from GCCG performance against those targets which link to the organisations objectives:
Internal Perspective Organisational Objective Clinical Excellence (1) Develop strong, high quality, clinically effective and innovative services. We will deliver this through a multi professional focus, with a particular emphasis on clinical programme approach and developing our member localities.
Finance and Efficiency (3) Transform services to meet the future needs of the population, through the most effective use of resources; ensuring the reduction of harm, waste and variation.
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(4) Build a sustainable and effective organisation, with robust governance arrangements throughout the organisation and localities. Patient Experience (2) Work with patients, carers and the public; to inform decision making.
Partnerships (5) Work together with our partners to develop and deliver ill health prevention and care strategies designed to improve the lives of patients, their families and carers.
Staff (6) Develop strong leadership as commissioners at all levels of the organisation, including localities.
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2.1 Clinical Excellence 2.1.1 Clinical Excellence – Period up to 31st October 2016
The overall rating for clinical excellence is Amber for year to date progress against the specified success criteria.
PERSPECTIVE 1 Clinical Excellence Amber
Success criteria: 1. Regular, robust information is available to provide assurance that our service providers are delivering quality, Green safe & clinically effective services. Key performance indicators A robust process to timely monitor compliance with NICE, which provides assurance that all NICE publications are considered and Technology Appraisals are implemented within 90 days (or to have a valid reason if not which has gone through appropriate governance process).
Number of NICE TAs published and relevant to CCG Green
Clinical Quality Review Groups meet quarterly and provide assurance to the Governing Body through the production of a bi-monthly provider quality report. Ad-hoc meetings take place with providers on specific concerns. The Clinical Effectiveness Group (CEG) is a sub group of CCG Integrated Governance and Quality Committee (IGQC). The CEG meets bi-monthly and identifies areas of best practice or concern in relation to quality outcomes or evidence based practice. It also monitors compliance or deviations from published NICE Guidance. Where concerns are identified a ‘Pink Slip’ is sent to the provider (via Green the appropriate CQRG) which asks for information and highlights the area of concern. On behalf of the CCG it seeks assurance that these are being addressed by appropriate action plans. These together facilitate an auditable process around ensuring best practice. The National Audit Review Group (NARG) is a sub group of the CEG which enables the CCG to review national clinical audit results and to gain assurance that providers of these services conform to these recognised standards of care (also by means of a ‘Pink Slip’).
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Success criteria: 2. Commissioning high-quality primary care services through the utilisation of exercising Delegated Green Commissioning responsibilities within a robust governance structure Key performance indicators Commission all Gloucestershire practices through a ‘Primary Care Offer’ enhanced service for 2016/17 that focuses on clinical quality Green improvement, reduces variation, tackles health inequalities and promotes innovation Set-up and implement a Primary Care Clinical Quality Review Group (CQRG) and develop a set of indicators to measure primary care Green quality
Success criteria: 3. Progress in developing and implementing Green locality plans Key performance indicators
Reporting progress on implementation of the seven Locality Green Development Plans for 2015-2017. Success criteria 4. Progress to develop outcomes for CPGs CPG success criteria & KPIs Outcomes – CPG programme/timelines in outline in appendix, KPIs re staying to timetable, output etc, narrative In development to focus, in brief, on one CPG area per month
Success criteria: 5. Key local and National standards relating to Amber Patient Experience Key performance indicators Achievement of key local and National standards relating to Clinical Amber Excellence – see section 2.2 to 2.9
2.1.2 Success criteria 1: Regular, robust information is available to provide assurance that our service providers are delivering quality, safe & clinically effective services.
The Quality Team has established quarterly Clinical Quality Review Groups (CQRG) chaired by the Executive Nurse and Quality Lead. These are held for Gloucestershire’s main providers, namely Gloucestershire Hospitals NHSFT, 2G NHSFT and Gloucestershire Care Services Trust. Further CQRG’s are held for Care Homes and Primary Care. These meetings report directly to the relevant NHS Gloucestershire CCG/Provider contract boards, and provide a focused opportunity for quality to be discussed between provider and commissioner.
CQRG’s have the ability to escalate any issues to the full contract board, and where necessary to the regular wider NHS England Quality Surveillance Group
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meetings. Updates and minutes from CQRG’s are routinely reported to IGQC for assurance purposes.
2.1.3 Success criteria: 2: Commissioning high-quality primary care services through the utilisation of exercising Delegated Commissioning responsibilities within a robust governance structure.
Since April 2015, GCCG have been responsible for commissioning primary medical care services through a delegation agreement with NHS England. The Primary Care and Localities Directorate, working with the Primary Care Operational Group (PCOG) and the Primary Care Commissioning Committee (PCCC), manage this within a good governance process that minimises any real or perceived conflicts of interest.
In the Quarter 4 2015/16 NHS England assurance, Gloucestershire received an ‘Outstanding’ rating for exercising delegated commissioning arrangements.
The CCG’s Primary Care Strategy for Gloucestershire: Joining Up Your Primary Care was approved in September 2016. The Strategy sets out a draft vision for Primary Care, with a plan to achieve it over the next five years:
“So patients in Gloucestershire can stay well for longer and receive joined-up out of hospital care wherever possible, we need to have a sustainable, safe and high quality primary care service, provided in modern premises that are fit for the future. To do this, we will:
Attract and retain the best staff through promoting Gloucestershire as a great place to live and work, and offering excellent training opportunities; Ensure good access to primary care 7 days a week; Create a better work-life balance for our staff; Maximise the use of technology; Reduce bureaucracy; Support practices to explore how they can work closer together to provide a greater range of services for larger numbers of patients.”
The Primary Care Offer for 2016/17 builds on the success of the previous two years. The key activity themes are:
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Activity against these themes has commenced, with reporting on outcomes to
follow in the second half of 2016/17.
2.1.4 Success criteria 3. Progress in developing and implementing locality plans
All seven CCG localities have developed two year Locality Development Plans running from 2015-2017. Each plan was developed in conjunction with their member practices, CCG colleagues and local stakeholders including Public Health colleagues and representatives from the District and Borough Councils to understand the influencing factors on health and wellbeing within each locality. These have been shared with a wide range of stakeholders across the county, including practice Patient Participation Groups (PPGs).
Progress against all seven Locality Development Plans is being reported six monthly to the GCCG Governing Body, with in-depth reporting on individual localities quarterly to the CCG Development Session.
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All localities have also been working on the implementation of the Prime Minister’s GP Access Fund projects, such as Choice+, to pilot the schemes within their areas.
In addition, across the county, the GCCG Primary Care and Localities Directorate have been supporting localities in formulating the vision for primary care in the future. Given the current resilience and sustainability issues being experienced within General Practice, along with the latest national policy direction of primary care working ‘at scale’ to lead an integrated out-of-hospital care system, the locality infrastructure is well placed to organise and co-ordinate events to help develop the ideas locally. These events have now led to the development of a GP Provider Leadership Development programme, with identified leads from each locality. This GP membership has formed the basis of the ‘New Models of Care Board’, along with the Chief Executives of our Provider organisation partners, with the inaugural meeting held in July. 15 clusters have formed across the county within the seven localities as a result of this work and are now developing local place-based ideas and plans, while Locality Development Plans continue to be implemented:
The place based model is established in Stroud and Berkeley Vale with the 4 clusters finalising their plans. The model will roll out to Gloucester City commencing in November.
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2.1.5 Success criteria 4. CPG success criteria & KPIs Outcomes – CPG programme/timelines in outline in appendix, KPs re staying to timetable, output etc. narrative to focus, in brief, on one CPG area per month (timetable re which CPG each month)
Please see section 3.1.6
2.2 Reporting of key local and national standards – Clinical Excellence
The following section provides an overview of key local and national standard relating to clinical excellence. Assessment against performance is as per defined local/ national guidance. Sections 2.2.1 to 2.8 covers constitutional targets and local key performance indicators. Section 2.9 looks at the Improvement and Assessment Framework (IAF). This has been introduced by NHS England to replace the existing CCG framework. It is designed to fit in with the STP plans and supplies metrics for adoption in the plans as markers for success.
Issues identified in the following areas: Cancer 62 day GP referral
Cancer 2 week GP referral Incomplete RTT performance Cancer 31 day targets 6 week diagnostic waiting times A&E 4 hour target
2.2.1 As part of the 2016/17 planning cycle and in support of the sustainability and transformation plan for Gloucestershire, the CCG and GHNHSFT have been required to submit agreed performance trajectories for the following constitutional standards.
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A&E – 4 hours: National standard 95%
A&E Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Agreed trajectory 80.0% 85.0% 85.0% 87.0% 87.0% 91.9% 89.1% 91.2% 85.7% 85.1% 80.1% 89.6%
RTT incomplete pathways: National standard 92% RTT Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Agreed trajectory 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0%
Diagnostic 6 week: National standard 1% Diagnostics Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Agreed trajectory 2.7% 2.2% 1.5% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0%
62 Day cancer: National standard 85%
Cancer 62 days Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Agreed trajectory 77.2% 80.4% 82.6% 82.9% 84.4% 85.3% 85.0% 85.2% 85.0% 85.0% 85.1% 85.6%
rd The finalised trajectories were submitted on the 23 May, for the purposes of this report the RAG rating applied to the above metric will be based on achievement of the trajectory as opposed to the national performance standard.
2.3 Unscheduled care: The following dashboard provides a position statement for Unscheduled Care. Each of the Amber and Red rated indicators are reported on by exception in section 2.3.1. This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.
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Local and National standards relating to Clinical Excellence Latest YTD Unscheduled care Threshold Month 6 month trend Performance performance SWAST Ambulance indicators Ambulance Red response 75% Sep 69.8% 68.6% Ambulance Red 19T response 75% Sep 84.1% 83.5% CCG / SWAST/ GHNHSFT are Over 30 minute ambulance handover delays (GHNHSFT) undertaking some additional validation of handover numbers for Over 1 hour ambulance handover delays (GHNHSFT) 2016/17 A&E
4-hour A&E target GHNHSFT 89.1%* Oct 86.0% 87.4%
4-hour A&E target GCS MIU 95% Sep 99.6% 99.6% 12 hour trolley waits 0Oct0 1
2.3.1 SWAST Ambulance indicators
Key performance and activity indicators:
. SWAST Red response rate improved in September making the year to date position 68.8% (Ambulance Response Programme was initiated 18/04) . Ambulance incidents with response indicate a decrease for months April to September 2016, with 264 fewer incidents than during the same period in 2015/16.
. Gloucestershire Conveyance to A&E has increased compared to 2015/16 (39.4%), with 48.8% of incidents resulting in conveyance to A&E. The rise in A&E conveyance can be linked to the change in the Computer Aided Dispatch (CAD) system within the SWAST North Division. Prior to the change the old CAD had all hospital wards and MIU’s etc. programmed into the Mobile Data Terminals (MDT) on the ambulances. The new CAD doesn’t currently have the same level of detail in it, and so there may be instances where the final destination of the patients is not recorded correctly. SWAST are aware of the issue and are working to resolve it as soon as possible. A demand management plan for Gloucestershire is in place with SWASFT and identified as part of the Improvement Plan and the Right Care 2 Programme.
SWASFT is participating in the Ambulance Response Programme Code Set Trial (ARP) which has seen a change to the way in which ambulance responses are measured. This change took place on the 19th April 2016. This pilot project is being extended by NHS England and it will extend the trial to all Ambulance trusts in Quarter 4 of 2016/17, following a review undertaken by Sheffield University.
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Performance is measured against the Red 8 minute response in September was 69.8%, with a year to date of 68.6%. Red 19 minute response was 84.1% with a year to date of 83.5%
Ambulance incidents with response indicate an decrease for the month of September of 4.5% below contract, and an overall decrease for months April to September 2016, with a variance to commissioned contract activity of -3.59%.
During April to September 2016/17, hear and treat cases accounted for 12.4% of activity, conveyance to A&E continues increased compared to 2015/16 with 49% (22,024) of incidents resulting in an A&E attendance.
Ambulance activity and outcome variance April and May 2016 (compared to same period in 2015/16):
Ambulance outcome* M6 2015/16 M6 2016/17 Change %
45239 44975 ‐264 ‐0.6% Total incidents Hear and Treat 5300 5556 256 4.8% See and Treat 16984 14710 ‐2274 ‐13.4% See and Convey (Total) 22955 24709 1754 7.6% See and Convey (A&E Department) 18816 22024 3208 17.0% See and Convey (Other Destination) 4139 2685 ‐1454 ‐35.1%
*NB: The rise in A&E conveyance can be linked to the change in the CAD system within the SWAST North Division.(see 2.3.1)
2.3.2 4-hour A&E target - Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge.
Threshold – at least 95% of patients should be transferred, admitted or discharged within 4 hours (STP trajectory for October – 89.1%).
ED Performance year to date was 87.6%, which is 0.9% above the STP YTD trajectory. October performance was 86% (STP trajectory was 89.1%).
ED attendances at GHT have been higher than during 2015/16 across all weeks. The year to date positon is +6.6% (4,293 attendances) Self-referral is the biggest growth areas for ED attendances in 2016/17 with an additional 11.8% (3,273 attendances). The proportion of patients admitted following an ED attendance stands at 32%, below 2015/16’s proportion of 34%, though this has seen a decrease in the most recent six weeks.
Arrival time in ED for admitted patients: there has been an increase in
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attendances between 10am and 12pm and at 9pm. The most significant increase in admission time is between 9am and 4pm, there has also been growth from 10pm through to 2am. Length of stay is 5.0 days which is slightly above 4.9 days in 2015/16.
The system have an agreed improvement plan for 4 hours, this is based on 11 work programmes within the Trust. Specific areas of focus are the reduction in emergency admissions and a reduction in acute bed base capacity. Key actions include:
GP In ED (Front and back door) – supporting attendance/ admittance avoidance. Pathway compliance including enhanced utilisation of AEC/OPAL Development of new pathways for patients direct to assessment units. Reviewing primary care and work that may impact on surge Working with 111 on enhanced clinical validation to reduce 999/ED dispositions
Reviewing staffing model to provide enhanced mental health liaison service
in ED
Reviewing staffing models and corresponding capacity within SWASFT to
enhance 999 service offer.
Working with community provider to actively reduce current community hospital length of stay Development of community based IV service Enhancing role of single point of clinical access to support admission avoidance including access to specialised advice line within the acute trust Ongoing work within the acute trust to deliver SAFER principles of discharge Development of discharge to assess beds with progression on home-based pathways
2.4 Planned care:
The dashboard provides a complete position statement for Planned Care. Each of the Amber and Red rated indicators are reported on by exception in section 2.4.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.
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Latest YTD Planned care Threshold Month 6 month trend Performance performance Referral to treatment (RTT)
% of incomplete Pathways that have waited less than 18 Weeks 92% Sep 91.5% 92.3% Zero RTT pathways greater than 52 weeks 0 Sep 10 62 Cancer waiting times % of patients seen within 2 weeks of GP referral for suspected 93% Sep 88.4% 86.6% cancer % of patients seen within 2 weeks of an urgent referral for breast 93% Sep 96.3% 93.5% symptoms cancer is not initially suspected Cancer - first definitive treatment within 31 days of a cancer 96% Sep 99.0% 99.1% diagnosis Cancer - subsequent treatment for cancer within 31 days - 94% Sep 100.0% 99.7% surgery Cancer - subsequent treatment for cancer within 31 days - Drug 98% Sep 100.0% 99.7% Regime Cancer - subsequent treatment for cancer within 31 days - 94% Sep 94.7% 99.0% Radiotherapy Cancer - first definitive treatment within 62 days GP referral 85.3*% Sep 78.1% 78.5%
Cancer - first definitive treatment within 62 days screening 90% Sep 100.0% 94.0% service Cancer - first definitive treatment within 62 days upgrade 85% Sep 100.0% 94.1%
Diagnostic waiting times
% of patients waiting more than 6 weeks diagnostic test 1%* Sep 2.5% 1.9% Local community waiting times % referred to the Paediatric Speech and Language Therapy 95% Sep 99.1% 98.2% Service who are treated within 8 Weeks % referred to the Paediatric Occupational Therapy Service who 95% Sep 96.0% 96.6% are treated within 8 Weeks % referred to the Paediatric Physiotherapy Service who are 95% Sep 94.0% 97.4% treated within 8 Weeks % referred to the Adult Speech and Language Therapy Service 95% Sep 98.9% 93.9% who are treated within 8 Weeks % referred to the Podiatry Service who are treated within 8 95% Sep 96.0% 96.6% Weeks % referred to the Adult Occupational Therapy Service who are 95% Sep 94.6% 92.3% treated within 8 Weeks % referred to the Adult Physiotherapy Service who are treated 95% Sep 88.3% 91.9% within 8 Weeks % referred to the Parkinson Nursing Service who are treated 95% Sep 100.0% 98.3% within 8 Weeks % referred to the Diabetic Nursing Service who are treated 95% Sep 96.0% 97.1% within 8 Weeks YTD Elective cancellations Threshold MonthPerformance 6 month trend performance
Cancelled operations - 28 day breaches 0Aug4 43
*STP Trajectory
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2.4.1 Referral To Treat (RTT) incomplete pathways and Referral to treatment (RTT) pathways greater than 52 weeks
In September there were 10 patients who were waiting longer than 52 weeks for treatment.
Ongoing capacity issues within the complex spinal service are the primary cause for the 7 breaches at North Bristol Trust (3 in T&O, 3 in Neurosurgery, 1 in Neurology), three at NBT have been allocated dates to come in within November.
There was 1 52 week breach at GHNHSFT in Urology and 2 at Oxford University Hospital in T&O, these patients have all had treatment during October or November.
There has been an increase in Gloucestershire patients waiting over 35 weeks at the end of September, with 311 compared with 278 in August. The effectiveness of this process is being reviewed to ensure that all opportunities for patient transfer are maximised.
The CCG regularly receive updates on the progress of treatment for Gloucestershire patients at out of county providers. All patients have been clinically reviewed and we regularly request patient TCI dates. Performance management is being undertaken in conjunction with the lead commissioner for planned care. As an associate commissioner, we receive the monthly performance position highlighting the issues and have an opportunity to challenge progress. Some of the key recovery actions taken include:
A Risk of Harm report sent to GHFT Quality & Performance Committee GHNHSFT RTT Recovery plan has been drafted and sets out plans to recover performance by speciality. GHNHSFT are also investigating how to expedite recovery with CCG support Other capacity – Nuffield discussing levels and which specialities immediate discussions T&O, General Surgery and possibly Gynaecology Further communication to GPs to raise awareness of current pressures and performance at GHFT – waiting times of other providers to be shared Referral pathways being discussed with CPG leads. 52 week waiters - Ensure early warning flag system at 35 weeks is in place and robust.
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G-care Website
The G-care website has been designed for use by clinicians working in primary care, specifically to support Gloucestershire based GP’s in their work. The website pulls together useful information from a range of sources and includes local care pathways, clinical guidance, referral forms, patient and care information, service information, as well as links to community resources such as social prescribing and voluntary sector groups. There have been 324 new users visit the site in October bringing the total number of unique visitors to the site to 1472. The site was visited 3,506 times with 12,423 pages viewed.
https://g-care.glos.nhs.uk
October 2016
Total Users 1,472
New Users 324
Site Views 3,506
Page Views 12,423
Top Pages Viewed 1. Deep Vein Thrombosis
2. Ambulatory Emergency Care
3. Irritable Bowel Syndrome
4. Antibiotic Use
5. Social Prescribing
Top Referral Forms 1. Individual Funding Request Form – GP’s
2. Gloucestershire Respiratory Service
3. Complex Leg Wound Service
4. Suspected Colorectal Cancer
5. Gloucestershire Podiatry Service – Diabetic Foot
Content Updates Remote Monitoring - Telehealth
Social Prescribing Tewkesbury – Referral Form
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Stability and Balance Class Updates
Top Site Searches 1. Asthma
2. Podiatry
3. DVT
4. Antibiotic
5. Osteoporosis
2.4.2 Cancer waiting times – first definitive treatment within 62 days GP referral – Threshold: 85% (STP trajectory for September 85.3%)
Delivery of cancer targets continues to be challenging in 2016/17.
2 Week Cancer waits
Performance against the 2-week wait target increased to 88.4% in September. There were 190 breaches of which the main area of concern was still within the Urology service at GHFT (84 breaches), Skin (28 breaches) & Lower Gastro intestinal (25 breaches). GHNHSFT have put in place actions to improve performance which include:
• 2WW Appointment Booking Project: CPG team have already implemented an information campaign with practices to ensure patients understand the importance of attending 2WW appointments. A new joint “task & finish” project to be launched this week to understand problems and implement short-term improvements. • Referral Pathways: There has been extensive discussion about the shift that is evident from routine referrals to 2WW referrals. This was expected as a result of the new NICE guidelines, however as a system there is a need to have a full appreciation of any other factors and understand the current availability and waiting times for routine appointment too as part of this pathway work. A number of potential solutions were discussed, these will be investigated further.
62 day cancer waits
Performance against the 62-day wait target declined from 79.5% in August to 78.1% in September, with 32 breaches of which 15 were in Urology and 6 in Lower Gastro intestinal. The Trust performance is on track with the improvement trajectory agreed. Other actions for recovery include:
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The implementation of the new service model, one-stop MAD Clinics, is progressing. A tight focus on maintaining progress is required Urology Peer Review: An in-depth external visit recently undertaken, included very positive support for the improvement actions being enacted Timed Pathways: some good progress made on confirming all current pathways. However we requested greater clarity on the status and reporting of the timed pathways Capacity review: some detailed discussion on ensuring key recruitment and equipment enhancement are remaining on track.
104 day breaches
There were 15 over 104 day breaches reported at the end of September. The number of patients in this category is tracked weekly by the Trust, the CCG have requested weekly updates to be shared.
Urology remains the speciality of most concern with ongoing discussions between
GHNHSFT and GCCG regarding recovery actions. The key actions in October have focused upon creating capacity at GHNHSFT:
GHNHSFT have plans to expand the current multidisciplinary and diagnostic clinics which will shorten patient pathways. Business case in in development.
GP Care are operating a clinical assessment service in conjunction with GHNHSFT and GCCG. In the 12 months (November 15 to October 16) since the service was commissioned it has accepted 1237 referrals and has so far seen 1034 of those patients. On average, to date 73% of patients complete their pathway with GP Care, with 27% going on to GHFT for surgery.
GCCG have agreed a recovery trajectory with GHNHSFT with performance against the standard being achieved by January 2017. Additional CCG support has also been provided to GHNHSFT to support the recovery plan process to ensure that performance improves, with sustainable delivery during 2016/17. The CCG organised a tripartite meeting with GHNHSFT & NHSI to discuss the 62 day Cancer position in September.
Percentage of patients waiting more than 6 weeks for a diagnostic procedure
There has been significant pressure on the 6-week diagnostic waiting time target, with performance challenged in particular in the Audiology, cystoscopy & Urodynamics services.
Performance in September at 2.5% has failed to meet the target (STP target of 1%)
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with the majority of breaches due to Audiology (175 breaches). Year to date performance is 1.9% against an YTD STP target of 1.6%. The underlying cause is a lack of audiologists which has caused a delay to some treatments.
The CCG is sourcing additional capacity to support this speciality. They are also looking at available capacity in Great Western Hospital which would be targeted at residents closer geographically to GWH. The CCG will continue to monitor the audiologist vacancy situation and if required look at an AQP contract for alternative provision.
2.5 Mental Health:
The dashboard below provides a position statement for mental health indicators. Each of the amber and red rated indicators are reported on by exception in section 2.5.1 This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.
Mental health indicatorsThreshold Month Performance YTD 6 month trend Dementia diagnosis rate 67% Aug 67.4% 67.4% Care Programme Approach (CPA) discharged from inpatient 95% Sep 95.0% 98.0% care who are followed up within 7 days IAPT Access rate: Access to psychological therapies for adults 6.25% Sep 3.72% 3.72% should be improved The proportion of people who complete therapy who are moving 50% Sep 41.0% 48.0% towards recovery IAPT - Waiting times: Referral to Treatment within 6 weeks 75% Sep 31.0% 33.0% (based on discharges) IAPT - Waiting times: Referral to Treatment within 18 weeks 95% Sep 82.0% 86.0% (based on discharges) CYPS Mental Health Threshold Month Performance YTD Children and young people who enter a treatment programme to 98% Sep 99.0% 99.0% have a care coordinator - (Level 3 Services) (CYPS) 95% accepted referrals receiving initial appointment within 4 weeks (excludes YOS, substance misuse, inpatient and 95% Q2 98.0% 99.0% crisis/home treatment and complex engagement) (CYPS) Level 2 and 3 – Referral to treatment within 8 weeks , excludes 80% Q2 76.0% 77.0% LD, YOS, inpatient and crisis/home treatment) (CYPS) Level 2 and 3 – Referral to treatment within 10 weeks (excludes 95% Q2 93.0% 92.0% LD, YOS, inpatient and crisis/home treatment) (CYPS)
2.5.1 Dementia diagnosis rate (DDR)
Dementia diagnosis rate in October 2016 was 67.7% which has met the 67% target. The CCG has a robust plan in place to maintain the figure and has
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completed regular case finding audits.
Using Quality Improvement and Clinical Programme Approach methodologies, the Primary Care Dementia Pathway is being reviewed through extensive stakeholder engagement that includes those living with dementia. The review includes key national targets such as DDR and post diagnostic support, and has already identified a number of key issues such as secondary care responsibility for prescribing and monitoring dementia drugs leading to duplication and gaps in annual review. The focus of dementia in the local Sustainability and Transformation Plan will facilitate the shift to support primary care diagnosis of dementia.
Improving Access to Psychological Therapies (IAPT) -The proportion of people who complete therapy who are moving towards recovery
There are known discrepancies between nationally reported recovery figures and local reported figures from 2G.
2Gether NHSFT have an on-going programme of work that will help ensure better understand of the variances in reporting of data. 2G staff are being briefed and trained on the issues to ensure that true clinical performance of the service can be reflected within the national dataset and a new care pathway has been introduced.
During the recent NHSE Intensive Support Team (IST) visit, it was identified that some of the Improving Access to Psychological Therapies (IAPT) activity should not be counted towards the IAPT Access and Recovery rates as it was carried out by nurses who were not NICE compliant. By removing this activity 2G have shown improvement in their IAPT recovery results and Year to date figures are slightly below the target at 48%. This has however had impacted on the Access to IAPT services figure which is 3.72% against a monthly target of 7.5%
A member of the national IAPT Team is supporting 2G. They have also had an on- site visit from the NHSE Intensive Support team. 2G have created an improvement plan for access and recovery which has been shared with the CCG, which includes an internal productive review and the providing of an E-provision via an external company to improve access rates.
2.6 Patient transport:
The dashboard below provides a position statement for patient transport. Each of the Amber and Red rated indicators are reported on by exception in section 2.6.1. This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.
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Significant improvement is required in order to achieve all performance targets on a sustainable basis. A performance notice was issued in December 2015 and the CCG is closely monitoring the Arriva Transport Services Ltd (ATSL) remedial action plan and performance improvement trajectory. A further exception report was issued in May 2016 as ATSL failed to achieve the worst case performance trajectory level expected for PTS04 for the month of March and saw a downturn in performance from February 2016.
YTD Patient transfer servicesThreshold Month Performance 6 month trend performance Arrival within 45 minutes before, to 15 minutes after, booked 95% Sep 84.9% 84.4% arrival time Where booked prior to the day of travel, patients not to wait 85% Sep 79.9% 78.6% more than 60 minutes for their (outbound) journey Where booked on the day of travel, patients not to wait more than 4 hours for their (outbound) journey (within two hours for end 85% Sep 87.0% 83.5% of life patients)
2.6.1 PTS 04 - Arrival within 45 minutes before, to 15 minutes after, booked arrival time – Target 95%
Inbound on-time arrival is an area where performance remains challenging. A significant performance improvement in January 2016, following implementation of actions identified in the ATSL Remedial Action Plan, has not been sustained in subsequent months. September’s report shows an increase, with 84.9% of
patients arriving within key performance indicators (KPI) timescales. An exception
report has been issued against this KPI as the required trajectory, agreed in response to the contract performance notice, has failed to achieve the worst case performance trajectory expected for the month.
2.6.2 PTS 05 - Where booked prior to the day of travel, patients not to wait more than 60 minutes for their (outbound) journey – Target 85%
The response timeframe for these is one hour from the time the patient is ‘made ready’. Analysis for September shows that 79.9% were achieved within the one hour compared to the target of 85%. This is an increase from August, and still
well below that achieved in January. Performance for dialysis patients is
significantly higher than for the full patient cohort, reflecting the routine nature of these journeys.
Performance improvement in January 2016, following implementation of actions identified in the ATSL Remedial Action Plan, has not been sustained in subsequent months. An exception report will be issued against this KPI if there is further deterioration in performance below the agreed worst case performance
trajectory in coming months.
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2.6.3 PTS 06 - Where booked on the day of travel, patients not to wait more than 4 hours for their (outbound) journey (within two hours for end of life patients)
– Target 85%
September 2016 saw an increase in performance to 87% compared to a target of 85%. The high number of on the day bookings made by the Acute Trust for discharge and transfer, particularly those made at the end of the day, remain challenging for ATSL. In the 16/17 contract with GHFT a CQUIN around on the day transport bookings has been agreed. CQUIN payment is predicated on <50% of discharge/transfer bookings being made on the day. Actions to increase the number of bookings made in advance should support achievement of this target and improve patient experience. Actions outlined in the ATSL Remedial Action Plan will also support performance improvement.
2.8 Clinical quality:
The dashboard below provides a more complete position statement for clinical quality. Each of the Amber and Red rated indicators are reported on by exception in section 2.8.1. This section outlines year to date performance, identifies the issues leading to that performance and any mitigating actions being taken to improve performance.
YTD Clinical qualityThreshold Month Performance 6 month trend performance Infection control
Number of MRSA infections (Health Community) 0Sep0- 6 - Number of MRSA infections (GHNHSFT) 0Sep0- 1 -
Number of C.diff infections (Health Community) 157 Sep 12 71 Number of C.diff infections (GHNHSFT) 37 Sep 4 20
Mixed sex accommodation
Mixed-sexed accommodation breaches 0Sep0 140
Other quality indicators Number of Never Events 0Sep0 1
2.8.1 Number of MRSA infections (Health Community)
There was 7 MRSA cases reported year to date. 6 were pre 48hr (attributed to community care) and 1 post 48hr (attributed to acute hospital) A Post Infection Review (PIR) of each case was undertaken within 14 days as required by Public Health England.
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2.8.2 Number of total C. difficile infections (Health Community)
The threshold for 2016/17 has remained the same with 157 for the CCG, and 37 for GHFT.
Year to date performance is 20 cases of C. diff reported at GHNHSFT and 71 in the wider health community.
Breaches are reviewed by GCCG quality team.
Mixed Sex Accommodation breaches
During September, there were 0 breaches. All breaches are reviewed against the delivering same sex accommodation decision matrix agreed with GHNHSFT, NHSE and the CCG.
2.9 The New CCG Improvement and Assessment Framework
NHS England has introduced a new Improvement and Assessment Framework for CCGs from 2016/17 onwards, to replace both the existing CCG Assurance Framework and separate CCG performance dashboard.
The new CCG Improvement and Assessment Framework is designed to fit with the forthcoming Sustainability and Transformation Plans. It supplies metrics for adoption in those plans as markers of success.
Components: 4 domains; 6 clinical priorities. The 4 domains consist of 60 Key performance indicators, some of which are being developed in year.
Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; Better Care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas; Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends;
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Leadership: this domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity for example in managing conflicts of interest.
We have received the initial baseline results for 42 of the 60 KPIs in July and some have been updated in October.
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Improvement & Assessment Framework Dashboard Needs Greatest Need Data Not Yet Theme Top Performing Performing Well N/A Improvement for Improvement Available
Better Health562010 Better Care9533111
Sustainability010025
Well Led100032
Total: 15 12 5 3 7 18 Notes: The rankings have been based on our position from all 209 CCGs on the MyNHS website and our ratings have been based on our ranking position as follow; If ranked 1‐52 ‐ we have assumed we are 'Top performing' If ranked 53‐104 ‐ we have assumed we are 'Performing well' If ranked 105‐156 ‐ we have assumed we are 'Needs Improvement' If ranked 157‐209 ‐ we have assumed are are 'Greatest need for Improvement'
Please note the rankings and ratings are not those given by NHS England and may change
6 Clinical Priority Areas
New ‘Ofsted style’ ratings (Top performing, Performing well, Needs Improvement and Greatest need for improvement), with assessments overseen by independent groups, will be assigned in the following 6 clinical priority areas:
Mental health – chair, Paul Farmer, Chief Executive of MIND;
Dementia – chair, Jeremy Hughes, Chief Executive of the Alzheimer's Society; Learning disabilities – chair, Rob Webster, Chief Executive of the NHS Confederation and Gavin Harding, Learning Disability Advisor, NHS England (acting as co-chairs);
Cancer – chair, Sir Harpal Kumar, Chief Executive of Cancer Research UK; Diabetes – chair, Chris Askew, Chief Executive of Diabetes UK. Maternity – chair, Baroness Julia Cumberlege, Chair of National Maternity Review
Process The first assessment for each of these six clinical priorities was published on the MyNHS website in September 2016 with baseline performance and informs whether NHS England intervention is needed.
The aim is to ensure that data will be available at least quarterly for nearly all of these metrics. NHS England’s regional teams will ensure that the framework is discussed with CCGs during the year, through a rolling programme of local conversations drawing on expertise and insight from the
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national programme teams.
The formal annual assessment against the 2016/17 framework will be published in summer 2017. Each CCG will receive an annual headline assessment in one of four categories. The assessment will be a judgement, reached by taking in to account the CCG’s performance in each of the indicator areas over the full year. To ensure that the framework is being applied consistently, regional and national moderation will take place. NHS England’s Commissioning Committee will oversee the process and sign off the ratings. The Committee will also track progress in-year. Ratings will be published.
The current assessment for the 6 areas is:
6 Clinical Priority Areas: October 2016
Cancer Needs Improvement
Dementia Performing Well
Diabetes Performing Well
Learning Disabilities Needs Improvement
Maternity Performing Well
Mental Health Needs Improvement
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2.9.1 Cancer
People with urgent GP Cancers diagnosed at early referral having 1st definitive Cancer stage treatment for cancer within 62 days of referral
54.4% 79.8% of patients diagnosed at an of people treated within 62 early stage days
One-year survival from all Cancer patient experience Needs Improvement cancers
8.7 is the average score given by 71.3% patients asked to rate their one-year survival care on a scale from 1 to 10 (10 being best)
The main reason we are currently rated as Needs Improvement in Cancer is due to the 62 day cancer target being in the bottom quartile nationally. Improvement in this one indicator out of the bottom quartile will see our rating improve to Performing well. We have a 62 day cancer recovery plan agreed with GHNHSFT and expect performance to recover by January 2017.
It should be noted that Gloucestershire CCG has been identified as one of the CCGs with the most improved position in country on one-year cancer survivorship, and that we can also report significant improvements in cancer patient experience over the last 3 years. Nationally 2020 objectives have been set for these key indicators and our cancer clinical programme is ensuring we have the appropriate work plans in place.
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2.9.2 Mental Health
People with 1st episode of Improving Access to Children and Young People’s psychosis starting NICE- Psychological Therapies Mental Health Services - Mental Health recommended treatment recovery rate Transformation within 2 weeks of referral 70% 85% Percentage compliance with of 20 people with first a self-assessed list of 49% episode of psychosis starting minimum se rv ice of people who finished treament with a NICE- expectations for Children and treatment moving to recovery recommended package of Young People's Mental care treated within 2 weeks Health, weighted to reflect of referral preparedness for transformation Crisis Care and Liaison Out of area placements for Needs improvement Mental Health Services - acute mental health inpatient Transformation care - transformation
85% 25% Percentage compliance with Percentage compliance with a self-assessed list of a self-assessed list of minimum se rv ice minimum se rv ice expectations for Crisis Care, expectations for Out of Area weighted to reflect Placements, weighted to preparedness for reflect preparedness for transformation transformation
Mental Health is a particular area of concern for the CCG with the IAPT recovery rate performing in the bottom quartile nationally. We have also received a Needs immediate attention for our self-assessment return on out of area placements for acute mental patients. Improvement in both these Key performance indicators will see our rating rise to Performing well.
The CCG and 2G have agreed a recovery plan for the improvement of the IAPT recovery and access rate and have been support by the NHS England intensive support team. Actions have included redesigning the IAPT pathway which was implemented in November 2016. The CCG is also in discussions with 2G around improving the reporting of out of area placements in order to meet the compliance requirements of the self-assessment return.
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2.9.3 Learning Disabilities
Reliance on specialist Proportion of people with a inpatient care for people with learning disability on the GP Learning Disabilities a learning disability and/or register receiving an annual autism health check 36 48% per million registered of 3403 people on the GP Needs improvement population register
This indicates improvements are required in reducing our reliance on
specialist inpatient care for people with a learning disability and/or autism in
order to improve our rating to Performing well. The current identified
numbers of patients in receipt of inpatient care is being challenged at a
national level as there appears to be a discrepancy between the national
Transforming Care Programme and specialist commissioning numbers.
Gloucestershire is well placed to improve our local resilience with regards to
an increase in the range and type of community based provision. A new
assessment and treatment unit, plus place of safety beds are coming on
stream in the new year. These bed based services will augment our already
successful learning disabilities intensive support service (LDISS).
Commissioners are working on a system wide improvement and promotion
plan in order to increase the take up of annual health checks. Our current
performance of 48% is slightly above the national average of 47%. It is
hoped that the current plans will improve this further and improve our overall
rating.
2.9.4 Diabetes
Diabetes patients that have People with diabetes achieved all the NICE- diagnosed less than a year Diabetes recommended treatment who attended a structured targets education course 40.8% 4.7% In the top half of performers. 75.9% participation in the Performing well 75.9% participation in the NDA. NDA.
In order to move to Top performing we will need to improve the number of
people with diabetes diagnosed less than a year who attended a structured
education course, so that our performance is significantly above the national
average of 5.7% (approx. 4% improvement).
The most recent national diabetes audit (NDA) participation figures show that
the participation rate in Gloucestershire has increased from 75.9% in 14/15 to
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91% in 15/16. It has been recognised that the documentation of completed structured education is poor across England because it relies on practices in primary care coding completion of Structured Education. In Gloucestershire, the face to face courses are delivered by GCS in the community. Practices are informed about patients who have attended the education courses but they do not prioritise coding patients as completing courses because; they don’t recognise that this is what is being measured centrally they are not incentivised to do it by QOF and It is a low administrative priority.
It has been recognised nationally that both completion of Structured Education programmes and coding on completion needs to be improved.
The implementation of Mapmydiabetes across Gloucestershire should increase the number of people offered and attended structured education (although we still need to qualify how we can ensure this is coded appropriately on completion). The Diabetes Treatment and Care transformation Programme has allocated £40m for 17/18 and 18/19 and is asking for bids from CCGs to improve the recording of structured education and increase the uptake of structured education. It is expected that CCGs will increase the documented attendance by 10% year on year until 2021
At their next meeting (December 1st) the Diabetes CPG will be deciding on details of their bid which could involve: Use of health trainers to provide some of the structured education programme (to increase provision and offer alternative times and venues) Use of administration staff to code attendance of SE programmes centrally or in practices Alternative methods of informing practices of patients who have attended education allowing for more efficient coding Use of the CES to incentivise appropriate coding
Working with GHNHSFT to ensure patients with Type 1 diabetes
receive SE and that this is documented in primary care (for NDA).
We will also need to maintain our performance for diabetes patients that have achieved all the NICE-recommended treatment targets at above 40.2%.
NDA data suggest that we achieve targets for adult patients above the age of
65 (Type 2 diabetes) but fall below expectations for all adult type 1 patients and adult patients with type 2 diabetes under the age of 65 year.
We also underperform with children under the age of 18 with type 1 diabetes.
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The intention is to work with GHNHSFT to improve treatment targets for type 1 diabetes (and investigate whether the correct data is on primary care systems for NDA purposes). We will also consider how we improve treatment targets for adult type 2 patients under 65 years.
2.9.5 Dementia
Estimated diagnosis rate for Dementia care planning and Dementia people with dementia post-diagnostic support
78.5% 66.7% of patients with dementia of the estimated number of whose care plan has been Performing well people with dementia have a reviewed in the preceding 12 recorded diagnosis months
Latest performance figures published in October for our dementia diagnosis
rate at 67.7%. If we could also improve our Dementia care planning and
post-diagnostic support result by 1% or more, then we would move into Top
performing.
The Primary Care Clinical Audit Team (PCCAG) is working with practices on
case finding patients with dementia on practice lists. The MiQUEST query
identifies those who may have dementia but do not have a diagnosis, and
support is offered by the Community Dementia Nurses to review those with
the practice team to facilitate a primary care or secondary care diagnosis as
appropriate. It is anticipated that the impact of the audit will in Q4 16/17.
The primary care dementia pathway is currently undergoing review, with
potential service redesign to address a number of issues. For example,
closer collaboration between the Community Dementia Nurses and
Alzheimer’s Society Dementia Advisers
timely and appropriate use of information support for those with Vascular Dementia and Mild Cognitive Impairment
Improved annual dementia review is being addressed in GP Cluster Pilot, where CCG is working with 2gether NHSFT to review the current secondary care prescribing and review guidance for dementia drugs (ACIs) which has led to an inequitable process of annual review and reduced Community Dementia Nurse capacity.
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2.9.6 Maternity
Neonatal mortality and Women’s experience of Maternity stillbirths mate rnity se rv ice s
6.2 83.1 stillbirths and neonatal is the score out of 100 based deaths per 1000 births. A on six survey questions. similar rate to most other Among the CCGs with the
Performing well Choices in maternity services Maternal Smoking at Delivery
70.1 8.8% is the score out of 100 based of 1645 mothers smoked at on six survey questions. delivery Among the CCGs with the
We will need to improve either the Neonatal mortality & stillbirths or Maternal smoking at delivery performance so it is statistically significantly better than the national average figures (7.1% Stillbirths, 10.2% Smoking). If we are able to do this we should move into the Top performing rating.
Maternity services are performing well and the ambition is for services to become ‘Top rating’. In order to achieve this the CCG in partnership with GHNHSFT and key partners will implement the action plan associated with the National Maternity Review ‘Better Births’ Report (2016) to ensure we continue to improve women’s experience of maternity services and reduce stillbirths and neonatal mortality by : Developing and implementing different ways of engaging women and families in diverse communities in conjunction with Health watch and GHNHSFT through social media and other means.
Work with women, families and stakeholders to improve women’s experience of postnatal care
Implement the action plan relating to Saving Babies Lives, aiming to reduce stillbirths via smoking cessation and monitoring movements and growth of babies.
Develop community hubs and integrating better together services that support women and families in the early years including health visiting and children’s services.
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3.1 Patient Experience 3.1.1 Patient Experience – Period up to 31st October 2016
PERSPECTIVE 2 Patient Experience Green Success criteria 1: Patient safety is at the heart of the work of the CCG and is Green considered when planning service change and developments. Key performance indicators Outcomes measures for patient safety have been developed based on the CCG Green Outcome framework and sign up for safety initiative. Quality Impact Assessments are undertaken for all new proposed initiatives and service developments. This is considered by the QIPP assurance board before Green decisions are made to support new initiatives. Mitigation is planned where necessary to ensure patient safety. Success criteria 2: Reporting: Improve reporting of patient experience Green including FFT (Marion Andrews‐Evans) Key performance indicators All providers of NHS funded services commissioned by GCCG participating in patient and staff FFT Green All providers of NHS funded services commissioned by GCCG achieving at or above Amber national average in patient and staff FFT score All providers of NHS funded services commissioned by GCCG participating in National Patient Survey Programme (2015/16) Green
All providers of NHS funded services commissioned by GCCG achieving at or above Green national average results in National Patient Survey Programme (2015/16) Success criteria 3: The CCG has a programme of case reviews in place across urgent care reporting into system resilience to influence service redesign Green including CPGs. Key performance indicators CCG has a programme of case reviews across urgent care, which feed into System resilience / clinical programme groups as appropriate. Green Focus on emergency admissions and discharge. Green
Success criteria 4: National targets‐PROMs Green
Key performance indicators All providers of NHS funded services commissioned by GCCG participating in PROMs Green (2015/16) All providers of NHS funded services commissioned by GCCG achieving at or above Green national average PROMs results (2015/16) Success criteria 5: All active Clinical Programme Groups are working with patients to ensure experience is incorporated into the programme and Green outcomes
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Key performance indicators All CPGs have regular ‘lay’ input Green All CPGs receive and review patient experience data Green Work to ensure PE is incorporated within QIPP schemes Green Success criteria 6: Develop patient experience work within primary care through working with PPGs to help inform and influence commissioning Green across the whole spectrum Key performance indicators PPGs are informing countywide priorities and Locality developments Green All GP practices in Gloucestershire have a PPG by 31 March 2015 Green
3.1.2 Success criteria 1: Patient safety is at the heart of the work of the CCG and is considered when planning service change and developments.
The CCG has a strong focus on patient safety and this forms a standing item on the agenda of the Clinical Quality Review Groups. In addition the CCG is fully involved as an active member of the South West Patient Safety Collaborative.
In October, NHS Gloucestershire CCG won the Nursing Times Patient Safety Improvement Award, and was praised by the expert judging panel for its system-wide approach to sepsis which demonstrates the role that everyone can play in the safe and effective care of people across the community. They felt that Gloucestershire’s work has both depth and breadth as well sustainable impact, and that it could be replicated across the NHS.
GCCG is a ‘Beacon CCG’ and was one of the first CCGs to commit to the ‘Sign up to Safety’ campaign. The campaign is now approaching its second birthday and is truly national, stretching across 360 organisations. GCCG’s support of this campaign is indicative of the high level of commitment the organisation places on improving harm free care and supporting staff in speaking up when things do go wrong.
To further highlight the Sign up to Safety (SU2S) campaign and engage CCG member practices, the quality team are working with G-care to include medical safety alerts, educational information and safety information. G-care is considered the most appropriate medium to share this information as it is established and is the go to place for member practices. The safety section is now available in draft form and hopes to go live before Christmas.
As part of our ongoing work with the West of England Academic Health Science Network (AHSN), the CCG has identified an ‘innovator’ practice within to county to work with them on improving safety reporting and
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associated learning in Primary Care. The AHSN project is being developed across the whole of the West of England and aims to focus GPs and practice teams on the idea of increasing openness and transparency around patient safety, which will in turn improve the patient experience.
3.1.3 Success Criteria 2: Improve reporting of patient experience including FFT
The Friends and Family test no longer has a CQUIN attached and has become part of the national contract for all providers.
The data included in this report has been taken from the NHSE FFT website. All FFT data (including current and historic acute and staff FFT data) can now be found at: https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family- test-data/
June July August Nat Nat Nat Provider Ave Provider Ave Provider Ave GHT Inpatie Response nts Rate 21.00% 26.20% 18.10% 25.50% 18.90% 25.20% % Recomme nd 95% 96% 93% 96% 95% 95% % Not 1% 1% 2% 2% 1% 2%
GHT Response A&E Rate 8.30% 13.40% 11.60% 12.90% 26.70% 13.70% % Recomme nd 95% 86% 86% 85% 88% 87% % Not 3% 7% 9% 8% 6% 7%
Response GCS Rate % Recomme nd 96% 95% 96% 95% 94% 96% % Not 2% 1% 2% 1% 3% 1%
Response 2g Rate % Recomme nd 94% 87% 93% 88% 86% 88% % Not 2% 4% 3% 4% 4% 4%
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The latest data reported was in August 2016 (above). This shows a continuing increase in response rates and % recommend for the GHNHSFT A&E and Inpatient FFT. GHNHSFT awarded the FFT data collection contract to a new provider in April 2016.
3.1.4 Success criteria 3: Programme of case reviews
A programme of clinical case reviews has been developed to support the delivery of urgent/emergency care programme.
Case reviews are scheduled to review emergency respiratory admissions, emergency admissions of patients with cellulitis and emergency paediatric admissions.
These case studies are being undertaken with input from Governing Body GPs and localities and are being carried out in partnership with provider organisations.
In addition to these the CCG are working with GHNHSFT and community colleagues to review patients who have been in hospital for longer than 14 days. The learning from these deep dives will be shared across the system
and inform the ‘pull’ model being designed in collaboration with the
Integrated Care Teams.
A summary of these reviews will be shared with the A&E Delivery Board.
As a result of the case reviews information is being collated to improve
compliance with unscheduled care pathways to improve patient experience.
To augment the Case Review process, the CCG is currently investigating
with GHNHSFT how patient experience feedback can be collected from
patients whose case notes are included in Case Reviews.
Success criteria 4: National targets-PROMs
Patient Reported Outcome Measures (PROMs) assess the quality of care
delivered to NHS patients from the patient perspective. Currently covering
four clinical procedures, PROMs calculate the health gains after surgical
treatment using pre- and post-operative surveys.
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The four procedures are: hip replacements knee replacements groin hernia varicose veins
PROMs have been collected by all providers of NHS-funded care since April 2009.
PROMs measure a patient’s health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients.
PROMs casemix-adjusted scores and outliers — 2015-16 Provisional Publication date: May 12, 2016: Gloucestershire provider ‘not an outlier’ for all procedures. http://systems.hscic.gov.uk/maps/proms/20160512_1516/index.html
Success criteria 5: All active Clinical Programme Groups are working with patients to ensure experience is incorporated into the programme and outcomes
All CCG Clinical Programme Group activity is supported by lay involvement.
The Eye Care CPG was recently shortlisted for a prestigious national award. The Lay Champion was invited to the award ceremony in London.
Success criteria 6: Develop patient experience work within primary care through working with PPGs to help inform and influence commissioning across the whole spectrum
GCCG has established a Gloucestershire Patient Participation Group (PPG) Network.
The focus of the most recent event, held on 14 October 2016, was: reducing stigma in mental health, patient facing website and social prescribing and working with the community and voluntary sector. In response to requests from PPG members, two workshops have been arranged, facilitated by PPG members themselves, on the topics of ‘Developing your PPG’ and ‘Using online forums’. It is intended that the product of these workshops will be developed in to local fact sheets.
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Members of the CCG Engagement Team have recently been invited to attend a number of individual PPG meetings to discuss developments and to provide advice and guidance. Recent discussions have focussed on a possible merger between practices and a new capital development.
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4.1 Partnerships
4.1.1 Partnerships – Period up to 31st October 2016
PERSPECTIVE 3 Partnerships Green
Success criteria 1: Building effective partnership working by putting in place a joint planning and governance framework to improve outcomes for the Green Gloucestershire population Key performance indicators Developing a plan for Gloucestershire, via Gloucestershire Strategic Forum, to identify the most appropriate service roadmap for Gloucestershire to take Green forward the five year forward view
GSF work plan – develop further and deliver with partners including GCC. Green GSF work plan now the STP work plan. Further develop and maintain system wide BCF forum encompassing all providers across health and social care, independent sector and voluntary Green sector and housing.
Success criteria 2: Work with the voluntary sector alliance to take forward Green the work with the voluntary and community sector in Gloucestershire.
Key performance indicators Roll out social prescribing and build on the existing evaluation to take Green forward learning Develop the “kitemark” for voluntary sector organisation Green Develop a cultural commissioning programme in conjunction with the New Economics Foundation, National Voluntary of Community Council’s and Arts Green Council England Build capacity in the voluntary sector (re work with VCS) Green
Success criteria 3: Effective urgent care pathway to enable more patients to Green stay in their own home Key performance indicators Effective relationships across adult social and health care to enable: i) Reduce non-elective admissions which can be influenced by effective Green collaboration across the health and care system. ii) Reducing inappropriate admissions of older people (65+) in to Green residential care iii) Rehabilitation / reablement, increase in effectiveness of these services Green whilst ensuring that those offered service does not decrease
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iv) Effective joint working of hospital services (acute, mental health and non-acute) and community-based care in facilitating timely and Green appropriate transfer from all hospitals for all adults. v) To develop a system which measures patient experience of integration Year-end over time, allowing any improvements to be demonstrated. assessment Year-end vi) Enhancing quality of life for people with care and support needs. assessment
4.1.2 Success criteria 1: Building effective partnership working by putting in place a joint planning and governance framework to improve outcome for the Gloucestershire population (Green)
A series of facilitated workshops for GSF (Gloucestershire Strategic Forum) members have been held, with more planned over the coming months to review the current service models and review against the objectives within the Five Year Forward View.
4.1.3 Success criteria 2: Work with VCS to take forward the work of the voluntary & community sector organisations in Gloucestershire.
Roll out social prescribing and build on the existing evaluation to take forward learning
As a part of the CCG’s prevention and self-care agenda, we have worked with G.Doc and a range of voluntary and statutory partners to develop an innovative social prescribing model. Social prescribing is a structured way of linking patients with non- medical needs to sources of support within a community and of providing one to one support where this is needed. These opportunities may include: arts; creativity; physical activity; learning new skills; volunteering; mutual aid; befriending; and self- help, as well as support for a wide range of problems including: employment; benefits; housing; debt; legal advice; and parenting problems.
This scheme is now fully operational across the county with social prescribing hub coordinators accepting referrals from all 81 GP Practices in the county and from staff in the county’s 21 Integrated community Teams (ICTs) and staff from community hospitals. As at the end of July there had been 2360 referrals from across the county.
The external evaluation of social prescribing by the University of the West of England (UWE) has been received and will be presented to Governing Body in November. There were particularly positive impacts on the well-being of people who had participated in the programme and also a significant reduction in GP time in terms of appointments, home visits and telephone calls. In conjunction with partners, the CCG plan to tender the service later this year.
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Develop the “kitemark” for voluntary sector organisations engaged in social prescribing
The VCS Alliance has been instrumental in the development of a kitemark for social prescribing. To date in excess of 60 organisations have completed the questionnaire which seeks assurance in areas such as staff training and support, policies and procedures and insurance. A graphic for a kitemark for social prescribing is now in use. The VCS Alliance undertook a survey of the impact of social prescribing on organisations in the county and the findings will be included in the UWE report.
Develop a cultural commissioning programme
To build on our work on social prescribing, Gloucestershire has also been working alongside the New Economics Foundation, National Voluntary of Community Council’s and Arts Council England to understand how arts and culture can be used to improve the health and wellbeing of our local population.
During the summer, Arts and Cultural organisations from the VCSE were invited to apply for funding via the cultural commissioning grant programme. The aim of the grant programme is to test out opportunities for arts and culture interventions to support health and wellbeing outcomes for participants. The CCG received a total of 24 applications and awarded grants to six of the nine projects. Examples of successful applicants include singing for respiratory disease, mindfulness based art approach for chronic pain in men and a multi-art programme for young people exploring themes of social media; bullying; self-harm & violence in relationships.
Clinical Programme Groups will be working alongside clinicians, lay members and the VCSE to co-develop appropriate and effective service models. This will provide the opportunity for commissioners and the public to ensure that the pilots are designed in a way that provides meaningful and measurable outcomes.
The grant programme has been support by a number of partners including the VCS Alliance, Forest of Dean District Council, Gloucester City Council and Tewkesbury Borough Council. Create Gloucestershire (the county umbrella organisation for art and culture) have also supported the grant programme by developing capacity within the VCSE sector. This included supporting organisations with their applications and acting as a bridge between the sectors
The national cultural commissioning programme formally finishes in April 2016. The CCG and partners (CREATE Gloucestershire, Gloucester City Council, Tewkesbury Borough Council and the Forest of Dean District Council) have been working alongside the New Economics Foundation (NEF) and the National Council for Voluntary Organisations (NCVO) to help disseminate the work which has been undertaken in Gloucestershire. This includes contributing to national reports and presenting at a number of conferences (including the All Party Parliamentary Group for Arts, Health
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and Wellbeing)
The CCG recently re-advertised two grant projects focusing on how arts and culture opportunities may reduce barriers to engaging with weight loss programmes and how arts and culture could promote confidence and healthy lifestyles for people diagnosed with colorectal and prostate cancer. Bids received are currently being evaluated. Work is ongoing to co-develop and deliver the other 9 grant projects.
Build capacity in the voluntary sector (re work with VCS)
The CCG approved a draft framework and action plan which suggested ways in which we might work with, support and learn from the VCSE in future. We are on target in terms of the delivery of the action plan and led a conversation with partners on the areas covered by the framework during November. Further, place based, workshops are planned for Autumn 2016. The VCS Alliance will continue to support this piece of work.
Gloucestershire Health and Wellbeing Board and Leadership Gloucestershire have ratified a policy outlining how they will work to enable local communities to become more active, stronger and more sustainable, and in turn improve the health and wellbeing of local people. The Health and Well Being Board aims to ensure that this activity is joined up and learning is shared from community to community across the county. Its Enabling Active Communities objectives are designed to build community appetite and capacity for neighbourhood-level working, through three separate strands:
Using existing assets e.g. workforce, buildings and community hubs;
Building knowledge and resilience within individuals and communities and ensuring effective provision of advice and information;
Developing local solutions – working with communities to identify local needs and how these might be better met using new or existing partnerships.
Success criteria 3: Partnership working group established to review dashboard and set targets.
As part of the Better Care Fund submission, Gloucestershire health and well-being board (H&WB) have committed to delivering a number of key indicators/ outcomes for the residents of Gloucestershire.
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4.1.4 Reduction in non-elective admissions (general and acute)
Avoidance of hospital admissions helps to ensure the most effective management of social care requirements. Minimising delayed transfers of care and avoidable admissions transforms the quality of care of individuals, enabling service users to receive the most appropriate care in the most appropriate location.
Within Gloucestershire we have seen 2.5% growth in non-elective admissions over the period January 2014 to December 2015. The 2.5% has been calculated using the defined BCF metrics (based on providers monthly activity returns MAR).
The Gloucestershire BCF plans for reducing non-elective admissions are aligned with the Gloucestershire CCG and Gloucestershire Hospitals NHSFT plans for 2016/17.
Gloucestershire CCG’s plan is for a 1.6% reduction in non-elective admissions. Within this assumption growth is 2.5%, while revised contract baseline and admission avoidance schemes are estimated to make a 4% reduction.
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Reducing inappropriate admissions of older people (65+) into residential care
This indicator is part of the Adult Social Care outcomes framework (ASCOF). The number of permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population.
Gloucestershire plans to continue the trend in the reduction of service users entering residential and nursing care. The CCG forecast for 2015/16 was a 2% reduction on the 2014/15 baseline, which equates to a 17% reduction on the BCF baseline period.
Increase in the number of people at home 91 days post discharge
This indicator is part of the ASCOF. Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into re-ablement / rehabilitation services.
The proportion of people who were still at home 91 days after discharge increased by 4.6% during 2014/15, the plan is to improve to meet the south west average which represents a 4.1% increase by the end of 2016/17.
Focus and prioritisation continue in this area to ensure we have robust preventative and crisis management services in the community, in particular effective re-ablement services that support people post-discharge and help them to achieve their full potential recovery.
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Reduction in Delayed Transfers of Care (DTOC)
This indicator is based on the ASCOF Delayed transfers of care from hospital per 100,000 population metric.
Gloucestershire performance on delayed transfers compares favourably to the England average. The next version is due for publication Autumn 2016 but was not yet published as at 15th November 2016.
Figures available on the NHS England website show the total number of Delayed transfers of care for Gloucestershire by quarter and this is provided below.
Total DTOCs Period Change % Change (Acute + Non-Acute) Q4 2015/16 3,564 Q1 2016/17 4,062 +498 +14% Q2 2016/17 5,886 +1,824 +45%
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Across 2016/17 we have shown a 5% reduction from the Quarter 4 positon across the year as this is an area of focus for our system.
Improved Patient Experience
This is a locally set metric based on the Gloucestershire Care Services Integrated Community Teams Rapid Response Experience Comment Card.
The expectation is that this metric will assess the services ability to look at individual patient needs and improved health and social care outcomes.
A baseline was recorded during quarter 4 of 2014/15, with the following question asked of ICT rapid response clients, 'How likely are you to recommend our service to friends and family if they needed similar care or treatment':
2014/15 baseline results: 131/133 clients (98.5%) provided a positive response (95 extremely likely and 36 likely)
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The latest results collated at the end of December 2015 indicate that from the 1st of April 98.93% of respondents have provided a positive response.
The main question is supported by 6 further questions based on NHS voices:
1. I always knew who the main person in charge of my care was 2. I didn’t need to keep repeating how I was feeling and explain what I needed to different people 3. I was involved in discussions and decisions about my care as much as I wanted to be 4. Information was given to me when I wanted it 5. The information given to me was appropriate to my condition and circumstances 6. I feel the people I met were kind to me
The plan for 2016/17 is to increase the response rate from 14.6% during 2015/16 to 15% in 2016/17; this is in line with the national guidance on the Friends and Family test.
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Enhancing quality of life for people with care and support needs.
Locally selected measure which is part of the ASCOF. The indicator is based on responses to 6 questions within the Adult Social Care Survey.
Ambitions against the above indicators have been set by Gloucestershire Health and Well-Being Board. Health community QIPP schemes have been mapped to each of the relevant indicators to assess the impact and progress made against these ambitions.
Results for the 2014/15 survey showed a 3.8% reduction in quality of life from the 2012/13 baseline. The plan for 2016/17 is to reach the England average by meeting the original BCF target of 7.9 (6.4% increase on 2014/15). This will be assessed when the Bi-annual survey results for 2016/17 are published due Autumn 2016.
Carers Gloucestershire hosts the Gloucestershire Carers Alliance whose mission is to provide a strong, independent, diverse and inclusive carer-led and carer-centred group influencing policy and services to improve outcomes for all carers. Plans are in place to further develop relationships with the Alliance/Carers Gloucestershire to provide a route through which providers and commissioners of services can engage and hear views and feedback from carers.
All of the ‘carers’ services’ contracts include satisfaction surveys and are showing a strong positive response, with an increase in the number of carer’s assessments undertaken and evidence of meeting the 6 week target from referral to assessment. In addition, each contract in turn will be subject to a carer peer group evaluation, which includes monitoring of contracts and interviews with carers.
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Staff
5.1 Staff – Period to 31st October 2016
PERSPECTIVE 4 Staff Green
Success criteria 1: Attracting and retaining high quality staff aligned to Green the CCGs vision and values Key performance indicators Turnover - % of employees leaving the organisation 1.07%
Number of current Vacancies in structure 8
Success criteria 2: Personal development processes that are linked to Green the strategic plan Key performance indicators All staff should have a PDP (90% target) and should have had an Audit underway appraisal in the last 12 months
95% of staff who have completed their mandatory training by the end of
March 2017
Success criteria 3: Staff are Happy and Motivated Green
Key performance indicators Staff sickness levels 3.21%
Staff Survey Completed
Completion of updated OD plan Completed
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5.1.2 Attracting and retaining high quality staff aligned to the CCGs vision and values
Monthly turnover in October was 1.2%. The number of leavers since the 1st April is 20, giving a monthly average of 3.33 leavers per month.
As at the end of July 2016, there were 7 jobs in the recruitment process.
5.1.3 Personal development processes (PDP) that are linked to the strategic plan
The CCG has commenced the collection of staff PDPs. A full audit is underway to ensure all PDPs have been completed and recorded. Once records are updated, a review against strategic objectives will take place.
5.1.4 Staff are Happy and Motivated
Staff survey has taken place, and the results are being collated and will be reported on shortly.
Staff sickness levels for October are 2.49 %, However year to date has risen to 3.21% which is above the GCCG target of less than 3%.
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6.1 Perspective 5. Finance and Efficiency
6.1.1 Finance and efficiency – Period to 31st October 2016
Summary:
Perspective 2 Finance & Efficiency Amber
Success critieria: To ensure a financially viable commissioning organisation with an underlying recurrent Amber surplus Threshold Lower threshold RAG Surplus ‐ year to date variance to planned performance (%age) 0.10% 0.50% Green Surplus ‐ full year variance to planned performance (%age) 0.10% 0.50% Green Running costs year to date (variance to running costs allocation) Within RCA Green Running costs forecast outturn (variance to running costs allocation) Within RCA Green BPPC performance on non‐NHS invoices by value (year to date) 95% 80% Green Cash drawdown in line with planned profiles (%age variance) 2% 5% Amber
Amber Success critieria: QIPP Full year Forecast Threshold Lower threshold RAG QIPP ‐ full year forecast delivery to planned performance (%) 95% 75% Amber
The CCG is forecasting to deliver a surplus of £9.456m, which is in line with plan. There are significant risks to the achievement of the financial plan.
Known risks and pressures have been fully assessed and included within the CCG’s position with mitigating actions where appropriate. There is slippage on QIPP schemes within the financial year.
Financial risks are managed through a continuous review of budgets and proposed investments and the use of the CCG’s contingency reserve. All budgets and discretionary CCG expenditure has been and continues to be reviewed.
A revised urgent care reset plan has been developed by the community to address urgent care over performance which is forecast to impact on the financial position, this assessed impact has been included in the financial forecast
A revised prescribing plan has been developed and the part year impact included in the financial forecast
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The better payment practice code performance (for non-NHS invoices by volume) is in line with the targeted figure.
Key risks: Provider contracts over perform in excess of those levels provided within the year end forecast
Further slippage on QIPP schemes (noting that the current RAG ratings are embedded within current financial forecasts)
The urgent care reset plan does not have the forecast financial impact
Prescribing costs are volatile and there is a risk that the current growth trend will change and the revised prescribing plan will not have the forecast impact.
The overall assessment for the finance and efficiency perspective is amber, more detail is provided in the following sections.
6.2 Resources The CCG’s resource limit (see Appendix 2) is £835.9m. This includes all primary care co-commissioning delegated budgets. There were additional allocations this month for mental health waiting times £130k and £166k for GP improvement grants for two GP Practices.
6.3 Expenditure The financial summary as at 31st October 2016 shows a year to date surplus of £5.516m; which is in line with the plan. Further detail is shown at Appendix 3. Key budget areas with either a significant financial risk or forecast outturn variance are highlighted below:
Key Trend Forecast Indicates a favourable movement in the month Over/ (Under)
Spend Indicates an adverse movement in the month £’000 Gloucestershire Hospitals NHSFT The activity performance continues to show considerable pressures primarily within emergency and A&E activity. There are smaller overspends in adult critical care and audiology; these are partially offset by an underspend on drugs. £0
The challenges that have been raised with the Trust are still awaiting an outcome.
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The forecast outturn on this contract includes assessments of: the impact of the urgent care reset plan on emergency activity; this is now based on changes seen in emergency admissions over the past three months since implementation of the plan plus the assess impact of additional actions due to be implemented in December. the likely outcome of contractual challenges; the process to agree these is in place and a number have been resolved, those outstanding are anticipated to be resolved within the next month. A risk assessed view on the outcome of the challenges has been included in the forecast the impact of the work on follow up attendances. On this basis, the forecast outturn on this contract is breakeven. However, it should be noted that there is significant risk within this forecast.
Great Western Hospital NHST The contract is over-performing in most areas: - Elective surgery over performance is due to general surgery, trauma and orthopaedics and urology activity. - Non electives activity is over performing within geriatric Medicine, T&O multi trauma and general medicine.
There is an underspend in adult critical care. £1,014
A response has been received however it did not address the issues and our contract lead in conjunction with Swindon CCG are co-ordinating a response. There is 1 Long stay patient which is included within the forecast. Oxford University Hospital NHSFT Overspends are highlighted within all aspects of the contract however the overspend has not increased from the previous month. Overspends are within the following areas: - Elective activity, within spinal surgery, colorectal surgery and T&O - Day cases within gynaecology, respiratory medicine £360 and clinical Haematology - Non Elective activity within paediatrics and general medicine specialties. - Drugs, predominantly Adalimumab and Idelalisib.
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The CSU failed to act on our behalf in raising the letter and the deadline has now lapsed. Our contract lead will query the activity for September onwards and note historic concerns. There are 7 long stay patients, 47 critical bed days which are included within this forecast. There are 2 non admitted 52 week waiters in September in T&O. University Hospital Bristol NHST There are small underspends in a number of day case procedures. However, there are overspends in the following areas: - elective inpatient care within clinical haematology and gynaecology £213 - non elective care in cardiology, paediatric surgery, gynaecology and obstetrics.
There is a long stay adult ITU patient that has been included within the forecast. Winfield Hospital The forecast overspend on this contract has not increased from the previous month. Overspends being reported in: - elective activity in T&O and spinal surgery - outpatient attendances in spinal, urology and T&O specialties.
£989 Offsetting this, physiotherapy is below plan. A letter has been issued to the Trust and a meeting convened to discuss current over performance. The Trust has been asked to reconcile their slots available to NHS with those detailed in the plan and to provide details on referrals. University Hospital Birmingham NHSFT The forecast overspend on this contract has increased slightly in month. Overspends being reported in: - Day cases in hepatobiliary/pancreatic procedures with immediate complications. £141 - Drugs, primarily Antifibrinolytic and Haemostatic blood products. There are small underspends are within pancreatic surgery, but not enough to mitigate the overspends elsewhere. Worcestershire Acute NHST The forecast overspend on this contract has increased in month. Overspends being reported in: £160 - Electives, T&O and general surgery
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- Day Cases, cardiology, T&O and ENT - Non Electives, general medicine and T&O. Mental Health Non Contract Activity The forecast overspend on Avon & Wiltshire Mental Health Partnership Trust has remained static this month however still considerably overspent with invoices totalling £40k a £692 month against £11k budget. Communication with the Trust is ongoing to understand this activity increase and resolve pathway issues for patients. Learning Difficulties There are 3 new patients within this forecast and it also includes a potential transfer of cases under Transforming Care Partnership from January 2017. £34 Costs for Gloucestershire Voices, which are also included in this forecast, are under discussion with Gloucestershire County Council to work through the funding arrangements. Continuing Healthcare The increase in Funded Nursing Care announced in July is included within the forecast for CHC and totals £3.2m which is marginally offset by underspends within physical £2,724 disabilities and adult fully funded continuing health care positions.
Prescribing When comparing August 2016 against August 2015, there has been an increase in growth of 2.74% for the month itself. This has the effect of increasing the YTD Growth to (£710) 0.14% (from -0.47%). The overall forecast underspend for primary care prescribing has marginally reduced as a result
of this slight increase in Growth. Running costs This area has remained static this month with a reported underspend predominantly due to non recurrent vacancies. (£134)
6.4 QIPP (Appendix 4) Based on the information available indications are that there is further slippage to £3.11m against the plan. An additional scheme for GPs in ED has been incorporated within this position to mitigate some of the slippage that is currently being experienced.
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6.5 Run Rate
The graph above highlights the expenditure relating to programme budgets for this and the previous two financial years, compared to the resource available for programme excluding any reserves and the surplus. The in-month position in October shows that programme spend is above anticipated levels by £0.8m. Cumulatively the CCG is still above estimated spend for Programme by £3.7m. Additional QIPP schemes and greater stringency on spend is being evaluated to counteract this.
6.6 Cash (Appendix 5) At the end of October, the CCG has drawn down 58.83% of the total cash limit which is slightly higher than a straight line trajectory. This is due to the timing of payments made to Gloucestershire County Council for the Better Care Fund. The cash balance at the end of October was £2.3m.
6.7 Better Payment Practice Code (Appendix 6) It is a national target that requires the CCG to pay 95% of non-NHS trade creditors
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within 30 days of receipt of goods or a valid invoice. The current year to date performance stands at 98.52% invoices paid by value and 97.46% by volume; both being on target.
6.8 Statement of Financial Position (Appendix 7) The position shown includes the audited opening balances from the 15/16 Annual Accounts.
6.9 Financial Risk Risks to the achievement of the financial forecast are: Contract Performance A large number of the CCG contracts are variable and there is a significant risk of over performance against the contracted value, both in planned and in urgent care. There are a number of challenges that have been raised with providers that have yet to be resolved.
Prescribing The prescribing forecast is on plan, whilst growth rates have been decreasing this is a volatile budget and growth rates can change significantly in a month, other factors are national changes to category M drug prices and changes to NICE guidance.
Funded Nursing Care On 13 July, a 40% increase to the FNC rate was announced by Department of Health, back dated to 1st April. The impact on the CCG is an unplanned pressure of approx. £3.2m which is within the current position. The rates will be reviewed further as at 1 January 2017.
QIPP slippage Due to the nature and scale of system changes within the QIPP programme along with the number of live schemes for the organisation there is a high risk of further slippage to the programmes. The forecast includes the impact of the urgent care reset and follow up programme, these schemes are heavily dependent on partner input, if these benefits are not realised then this will impact on the overall financial position.
Estates New national arrangements have been undertaken this year to charge on a market rent basis which could leave the CCG with a significant pressure that nationally NHS England has agreed to fund non recurrently this year however we are currently awaiting formal confirmation that quantifies the level of support.
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Appendices: Ref Description 1 GCCG Dashboard 2016/17 2 Resource Limit Position 3 Summary Financial Position 4 QIPP Programme 5 Cash 6 Better payment practice code 7 Statement of Financial position
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Gloucestershire CCG 2016/17 Integrated Performance Scorecard Year / 2015-16 Jun-16 / Sep-16 / Dec-16 / Mar-17 / Year End Target Principal Delivery Targets Apr-16 May-16 Jul-16 Aug-16 Oct-16 Nov-16 Jan-17 Feb-17 Quarter to Outturn Q1 Q2 Q3 Q4 Forecast date Unscheduled Care Accident & Emergency Target 00 0 00 0 00 0 00 0 0 0 GRH Attendances 6,926 7,621 7,355 7,638 7,232 7136 7471 51,379 51,379 GRH Breaches 1,113 1,320 1,186 1,379 948 1,086 1,266 8,298 8,298 GRH % 5 83.9% 82.7% 83.9% 81.9% 86.9% 84.8% 83.1% 83.8% 83.8% CGH Attendances 3,851 4,233 3,988 4,331 4,103 4,167 4,226 28,899 28,899 CGH Breaches 463 172 282 297 111 164 367 1,856 1,856 CGH % 0 88.0% 95.9% 92.9% 93.1% 97.3% 96.1% 91.3% 93.6% 93.6% GHNHSFT Attendances 10,777 11,854 11,343 11,969 11,335 11,303 11,697 80,278 80,278
4-hour A&E target - Percentage of A&E attendances where the GHNHSFT Breaches 1,576 1,492 1,468 1,676 1,059 1,250 1,633 10,154 10,154 E.B.5 patient spent 4 hours or less in A&E from arrival to transfer, GHNHSFT % 5 85.4% 87.4% 87.1% 86.0% 90.7% 88.9% 86.0% 87.4% 87.4% admission or discharge GCS - MIU Atts 5,771 6,774 6,473 7,377 6,882 6,396 6,070 45,743 45,743 GCS - MIU Breaches 25 17 22 30 31 27 22 174 174 GCS - MIU % 0 99.6% 99.7% 99.7% 99.6% 99.5% 99.6% 99.6% 99.6% 99.6% PC in ED Attendances 244 345 268 279 326 349 295 2,106 2,106 PC in ED Breaches 0 0 0 0 0 0 0 00 PC in ED % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Overall ED Attendances 16,792 18,973 18,084 19,625 18,543 18,048 18,062 128,127 128,127 Overall ED Breaches 1,601 1,509 1,490 1,706 1,090 1,277 1,655 10,328 10,328 Overall ED % 90.5% 92.0% 91.8% 91.3% 94.1% 92.9% 90.8% 91.9% 91.9% Target 0 000000000000 0 0 GRH 0 0 0 0 0 11 12 hour trolley waits (no A&E attender should wait more than 12 E.B.S.5 CGH0 0 0 0 0 0 00 hours from the decicision to admit to admission) GHNHSFT total 00 0 00 11 GCS - MIU 0 0 0 0 0 00 Ambulance Cat A 8 min response - The percentage of Category A RED 1 Target 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% E.B.15.i incidents, which resulted in an emergency response arriving at the SWASFT % 72.7% 72.7% 72.7% scene of the incident within 8 minutes. Glos % 63.2% 63.2% 63.2% Cat A 8 min response - The percentage of Category A RED 2 Target 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% E.B.15.ii incidents, which resulted in an emergency response arriving at the SWASFT % 56.9% 56.9% 56.9% scene of the incident within 8 minutes. Glos % 54.9% 54.9% 54.9% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Cat A 19 min response - The percentage of calls resulting in an E.B.16 SWASFT % 86.1% 86.1% 86.1% ambulance arriving at the scene of the incident within 19 minutes. Glos % 87.2% 87.2% 87.2% SWASFT Red Responses 1,636 3,937 3,689 4,009 3,631 16,902 16,902 SWASFT Red Resp < 8 mins 1,092 2,718 2,577 2,644 2,510 11,541 11,541 SWASFT Red % 66.7% 69.0% 69.9% 66.0% 69.1% 68.3% 68.3% SWASFT Ambulance Response Programme (Trial) - Red Red 50th Percentile (mins) 6.6 6.3 6.3 6.6 6.3 6.4 6.4 Red 75th Percentile (mins) 9.2 9.0 8.8 9.6 8.9 9.1 9.1 Red 95th Percentile (mins) 18.0 16.7 15.8 17.8 17.2 17.1 17.1 Total Amber Responses 19,350 53,454 50,855 54,357 52,236 230,252 230,252 Amber Transport Responses 3,879 9,099 8,530 8,997 7,522 38,027 38,027 Amber T - 50th percentile (mins) 22.2 23.0 22.8 24.8 21.5 22.9 22.9 Amber T - 75th percentile (mins) 42.8 44.5 43.0 48.1 42.7 44.2 44.2 Amber T - 95th percentile (mins) 109.5 110.3 103.7 119.3 104.3 109.4 109.4 Amber Response Responses 12,178 35,954 33,794 36,115 24,184 142,225 142,225 SWASFT Ambulance Response Programme (Trial) - Amber Amber R - 50th percentile (mins) 19.7 22.3 21.8 23.1 20.5 21.5 21.5 Amber R - 75th percentile (mins) 36.5 41.5 40.6 43.3 38.2 40.0 40.0 Amber R - 95th percentile (mins) 85.2 94.6 91.5 100.6 86.2 91.6 91.6 Amber F2F Responses 3,293 8,401 8,531 9,245 20,530 50,000 50,000 Amber F2F - 50th percentile (mins) 15.2 16.7 17.2 18.8 19.8 17.5 17.5 Amber F2F - 75th percentile (mins) 29.1 31.7 32.3 36.7 36.3 33.2 33.2 Amber F2F - 95th percentile (mins) 74.6 78.9 77.5 95.6 86.8 82.7 82.7 Total Green Responses 4,715 12,682 12,229 13,112 12,713 55,451 55,451 Green Face to Face Responses 670 1,593 1,424 1,410 1,064 6,161 6161 Green F2F - 50th percentile (mins) 37.0 36.4 34.9 37.1 32.9 35.7 35.7 Green F2F - 75th percentile (mins) 77.1 79.4 69.2 76.4 79.3 76.3 76.3 Green F2F - 95th percentile (mins) 183.9 207.8 172.3 222.9 203.1 198.0 198.0 Green Transport Responses 571 1,469 1,385 1,531 1,853 6,809 6,809 SWASFT Ambulance Response Programme (Trial) - Green Green T - 50th percentile (mins) 47.7 48.9 48.0 49.2 47.8 48.3 48.3
1 Gloucestershire CCG 2016/17 Integrated Performance Scorecard Year / 2015-16 Jun-16 / Sep-16 / Dec-16 / Mar-17 / Year End Target Principal Delivery Targets Apr-16 May-16 Jul-16 Aug-16 Oct-16 Nov-16 Jan-17 Feb-17 Quarter to Outturn Q1 Q2 Q3 Q4 Forecast date Green T - 75th percentile (mins) 88.8 99.1 90.6 97.7 97.3 94.7 94.7 Green T - 95th percentile (mins) 218.3 230.7 199.8 234.9 226.7 222.1 222.1 Green Hear & Treat Responses 2,062 6,198 5,620 6,327 6,076 26,283 26,283 Green H - 50th percentile (mins) 5.6 6.4 6.0 7.3 5.9 6.2 6.2 Green H - 75th percentile (mins) 15.4 17.7 17.7 23.5 17.4 18.3 18.3 Green H - 95th percentile (mins) 51.2 58.2 63.5 74.6 61.5 61.8 61.8 Target 00 0 00 0 00 0 00 0 0 0 E.B.S.7 Ambulance handover delays - 30 to 60 mins (GHNHSFT) Actual 172 198 154 216 141 881 881 Target 00 0 00 0 00 0 00 0 0 0 E.B.S.7 Ambulance handover delays - over 60 mins (GHNHSFT) Actual 1 4 10 12 9 36 36 Target 00 0 00 0 00 0 00 0 0 0 E.B.S.8 Clear up delays of over 30 minutes Actual 225 285 265 302 295 1372 1,372 Target 00 0 00 0 00 0 00 0 0 0 E.B.S.8 Clear up delays of over 1 hour Actual 27 16 29 24 22 118 118 Delayed Transfers of Care (DTOC) Acute target 14 14 14 14 14 14 14 14 14 14 14 14 14 14 Local Number of Delayed Transfers of Care for acute patients Acute actual 13.6 23 12 16 35 22 22 22 Reimbursable Days for Acute DTOCs (Attributable to Social Local Acute only 0 0 0 0 0 0 00 Services) Non-acute target 10 10 10 10 10 10 10 10 10 10 10 10 10 10 Local Number of Delayed Transfers of Care for non-acute patients Non-acute actual 2 3 4 5 8 0.0 Harmoni 111 Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local Calls answered within 60 seconds Actual 92.4% 85.6% 92.2% 93.5% 91.3% 95.8% Target 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% Local Calls abandoned after 30 seconds Actual 1.7% 3.3% 1.5% 1.2% 2.0% 0.6% Target 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% Local Calls triaged Actual 84% 81.7% 81.3% 80.7% 79.2% 80.9% Target 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% Local % calls referred to ED Actual 6.0% 6.4% 6.1% 6.3% 6.6% 6.5% Target 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% Local Calls warm transferred Actual 38.2% 26.9% 32.3% 34.1% 29.0% 44.4% Target 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 00:01:00 Local Longest wait for an answer Actual - 00:10:46 00:11:19 00:09:29 00:08:47 00:12:46 Target 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 00:10:00 Local Longest wait for a call back Actual - 00:05:12 00:06:31 00:05:20 00:05:03 00:09:06 Planned Care Acute Care Referral to Treatment
Percentage of admitted non adjusted pathways treated within 18 Target ------E.B.1 Weeks Actual 83.4% 82.9% 78.7% 80.0% 81.3% 81.3%
Number of completed admitted non adjusted pathways greater than Target ------E.B.S.4 52 weeks Actual - 35 6 5
Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% E.B.2 Percentage of non - admitted pathways treated within 18 Weeks Actual 91.4% 91.5% 91.4% 89.8% 91.0% 91.0%
Number of completed non-admitted pathways greater than 52 Target 00 0 00 0 00 0 00 0 0 0 E.B.S.4 weeks Actual - 2 3 10 13 0 Number of specialties where non-admitted standard was not Local Actual - 14 14 14 14 delivered
Percentage of incomplete Pathways that have waited less than 18 Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% E.B.3 Weeks Actual 92.7% 92.7% 92.8% 92.0% 92.6% 92.6%
Target 00 0 00 0 00 0 00 0 0 0 E.B.S.4 Number of incomplete pathways greater than 52 weeks Actual - 10 12 9 13 0 Number of specialties where incomplete standard was not Local Actual - 9 7 7 6 delivered Cancelled Operations Cancelled operations - Number of patients who have had an Target 00 0 00 0 00 0 00 0 0 0 operation cancelled, on or after the day of admission, for non- E.B.S.2 clinical reasons that have not been offered another binding date Actual - 20 7 8 4 4 within 28 days 2 Gloucestershire CCG 2016/17 Integrated Performance Scorecard Year / 2015-16 Jun-16 / Sep-16 / Dec-16 / Mar-17 / Year End Target Principal Delivery Targets Apr-16 May-16 Jul-16 Aug-16 Oct-16 Nov-16 Jan-17 Feb-17 Quarter to Outturn Q1 Q2 Q3 Q4 Forecast date Urgent operations cancelled for a second time - number of Target 00 0 00 0 00 0 00 0 0 0 urgent operations that are cancelled by the trust for non-clinical E.B.S.6 reasons, which have already been previously cancelled once for Actual - currently not receiving data from GHFT non-clinical reasons Diagnostics Target 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Percentage of patients who have waited more than 6 weeks for one E.B.4 Actual breaches 414 119 126 52 711 711 of the 15 key diagnostic tests Actual Perf 4.5% 1.3% 1.4% 0.6% 2.0% 2.0% Cancer Waits Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% Percentage of patients seen within 2 weeks of an urgent GP or E.B.6 Actual breaches 353 226 151 165 895 895 GDP referral for suspected cancer Actual Perf 78.0% 86.6% 90.6% 90.1% 86.3% 86.3% Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% Percentage of patients seen within 2 weeks of an urgent referral for E.B.7 Actual breaches 11 11 19 14 55 55 breast symptoms where cancer is not initially suspected Actual Perf 95.0% 94.7% 90.9% 91.5% 93.1% 93.1% Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% Percentage of patients receiving first definitive treatment within 31 E.B.8 Actual breaches 4 1 3 2 10 10 days of a cancer diagnosis Actual Perf 98.4% 99.6% 98.9% 99.1% 99.0% 99.0% Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% Percentage of patients receiving subsequent treatment for cancer E.B.9 Actual breaches 1 0 0 0 11 within 31 days where that treatment is surgery Actual Perf 98.3% 100.0% 100.0% 100.0% 99.6% 99.6% Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% Percentage of patients receiving subsequent treatment for cancer E.B.10 Actual breaches 1 0 0 0 11 within 31 days where that treatment is an Anti-Cancer Drug Regime Actual Perf 98.4% 100.0% 100.0% 100.0% 99.6% 99.6% Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% Percentage of patients receiving subsequent treatment for cancer E.B.11 Actual breaches 0 0 1 0 11 within 31 days where that treatment is a Radiotherapy Treatment Actual Perf 100.0% 100.0% 98.1% 100.0% 99.5% 99.5% Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% Percentage of patients receiving first definitive treatment for cancer E.B.12 Actual breaches 27 33 27 32 119 119 within 62 days of an urgent GP referral for suspected cancer Actual Perf 80.1% 76.1% 81.8% 74.8% 78.3% 78.3% Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% Percentage of patients receiving first definitive treatment for cancer E.B.13 Actual breaches 2 3 1 0 66 within 62 days from an NHS Cancer screening service Actual Perf 91.7% 83.3% 95.0% 100.0% 92.6% 92.6% Percentage of patients receiving first definitive treatment for cancer Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% E.B.14 within 62 days of a consultant decision to upgrade their priority Actual breaches 0 0 0 2 22 status Actual Perf 100.0% 100.0% 100.0% 75.0% 88.2% 88.2% Long Term conditions Proportion of people who have had a stroke who spend at least Target 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% Local 90% of their time in hospital on a stroke unit (GHT Only) Glos 84.6% 89.0% 83.8% 86.2% 94.0% Target 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% E.A.S.1 Dementia diagnosis rate Glos 66.0% 66.1% 65.8% 66.2% 66.7% 27.57% Community Care Referral to Treatment (GLOUCESTERSHIRE only) Paediatric Percentage of patients referred to the Paediatric Speech and Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local Language Therapy Service who are treated within 8 Weeks Actual 95.9% 92.8% 99.5% 98.7% 96.7% 96.7% Percentage of patients referred to the Paediatric Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local OccupationalTherapy Service who are treated within 8 Weeks Actual 97.2% 97.4% 96.9% 96.7% 97.1% 97.1% Percentage of patients referred to the Paediatric Physiotherapy Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local Service who are treated within 8 Weeks Actual 97.6% 98.3% 99.1% 97.2% 98.1% 98.1% Adult Percentage of patients referred to the Adult Speech and Language Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local Therapy Service who are treated within 8 Weeks Actual 84.8% 88.6% 94.1% 100.0% 91.9% 91.9% Percentage of patients referred to the Podiatry Service who are Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local treated within 8 Weeks Actual 99.2% 99.3% 97.6% 92.6% 97.2% 97.2% Percentage of patients referred to the Adult Occupational Therapy Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local Service who are treated within 8 Weeks Actual 90.8% 90.5% 89.9% 92.8% 91.0% 91.0% Percentage of patients referred to the Adult Physiotherapy Service Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local who are treated within 8 Weeks Actual 93.6% 93.9% 92.7% 92.5% 93.2% 93.2% Specialist Nurses Percentage of patients referred to the Parkinson Nursing Service Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local who are treated within 8 Weeks Actual 100.0% 90.0% 100.0% 100.0% 97.5% 97.5% Percentage of patients referred to the Diabetic Nursing Service who Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Local 3 Gloucestershire CCG 2016/17 Integrated Performance Scorecard Year / 2015-16 Jun-16 / Sep-16 / Dec-16 / Mar-17 / Year End Target Principal Delivery Targets Apr-16 May-16 Jul-16 Aug-16 Oct-16 Nov-16 Jan-17 Feb-17 Quarter to Outturn Q1 Q2 Q3 Q4 Forecast gp g date Local are treated within 8 Weeks Actual 95.8% 95.0% 100.0% 95.9% 96.7% 96.7% Mental Health and Learning Disabilities Adults of Working Age
Proportion of those patients on a Care Programme Approach Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% E.B.S.3 (CPA) discharged from inpatient care who are followed up within 7 days Glos 98.2% 0.0% Improving Access to Psychological Therapies (IAPT)
The proportion of people who have depression and/or anxiety Glos target 1.25% 2.50% 3.75% 5.00% 6.25% 7.5% 11.25% 15.0% 3.75% 3.8% E.A.3 disorders who receive psychological therapies Glos actual 0.72% 1.250% 2.1% 2.1% 2.1%
The proportion of people who complete therapy who are moving Glos target 25.8% 25.8% 25.8% 33.50% 33.50% 33.5% 41.20% 41.20% 41.2% 50.00% 50.00% 50.0% 50.0% 50.0% E.A.S.2 towards recovery Glos actual 48.0% 52.0% 53.0% 53.0% 53.0%
The proportion of people that wait 6 weeks or less from referral to Glos target 75.1% 75.1% 75.1% 75.1% 75.1% 75.1% E.H.1_B1 their 1st IAPT treatment appointment against the no. of people who enter treatment in the reporting period. Glos actual - 40.0% 35.0% 35.0% 35.0% 35.0%
The proportion of people that wait 18 weeks or less from referral to Glos target 95.1% 95.1% 95.1% 95.1% 95.1% 95.1% E.H.1_B2 their 1st IAPT treatment appointment against the no. of people who enter treatment in the reporting period. Glos actual - 92.0% 89.0% 90.0% 90.0% 90.0% Quality Quality Indicators CCG 60 0 26 19 17 Eliminate mixed-sexed accommodation breaches at all providers GHFT 69 0 30 23 18 E.B.S.1 sites (patients) Care Services 0 0 0 0 0 2gether 0 0 0 0 0 GHT 0 0 0 1 0 Care Services 0 0 0 0 0 Number of Never Events 2gether 0 0 0 0 SWAST ------Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Percentage of all adult inpatients who have had a VTE risk GHNHSFT 94.0% 92.5% 94.0% 93.2% 93.2% assessment GCS 95.4% 96.0% 91.5% 96.7% 97.9% Cleanliness and HCAIs Methicillin Resistant Staphylococcus Aureus (MRSA)
Glos HC target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 E.A.S.4 Number of MRSA infections (Health Community) Glos HC actual 31 0 11 0 66
Number of post 48 hours MRSA infections post 48 hours (Acute GHNHSFT target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Trust) GHNHSFT actual 1 00000 11
Clostridium Difficile (C.Diff)
Glos HC target 15 12 12 16 16 8 12 10 9 16 16 15 142 157 E.A.S.5 Number of total C Diff infections (Health Community) Glos HC actual 14 17 17 11 15 20 94 94
GHNHSFT target 3 3 3 4 4 2 3 2 2 4 3 4 33 37 Number of post 48 hour C Diff infections (Acute Trust) GHNHSFT actual 5 3 1 4 1 4 18 18
Local Priorities
Glos HC target LP1 Reduction in COPD admission Glos HC actual n/a
Glos HC target LP2 Injuries due to falls per 100,000 population ages 65+ GHNHSFT actual 2,236
Glos HC target LP3 GHNHSFT actual n/a
4 Appendix 2 NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP
Current Assumed Resource Limit Position as at 31st October (Month 07)
2016/17 Cash R NR TOTAL Limit AS AT Month 06 2016/17 £000 £000 £000 £000
2016/17 baseline excl growth rolled forward 707,886 707,886 707,886
BCF 11,596 11,596 11,596 ETO 2,300 2,300 2,300 Future in Mind 1,100 1,100 1,100 Capital Grant 3,000 3,000 3,000 Market Rent 321 321 321 GPIT 1,622 1,622 1,622 Neurology 43 43 43 Court Liaison (35) (35) (35) Wheelchairs 462 462 462 Cross Border 135 135 135 Co Commissioning 75,113 75,113 75,113 Growth - Prog 15,421 15,421 15,421 Growth - Admin 28 28 28 Growth Co - commissioning 3,410 3,410 3,410 15/16 Surplus Bfwd 9,456 9,456 Maximum Cash Adj (1,227) Eating Disorders 311 311 311 Choice + 1,350 1,350 1,350 General Practice Resilience Programme 132 132 132 GP Development Programme - reception and clerical training 55 55 55 SWAST Resillience 1,774 1,774 1,774 Vulnerable Practices pilot funding 95 95 95
Last month total 822,402 13,173 835,575 824,797
Adjustments in month Mental Health 130 130 130 Improvement Grants 166 166 166 Adjustments actioned in month 296 296 296
TOTAL NATIONALLY REPORTED LIMIT 822,402 13,469 835,871 825,093 Appendix 3 NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP
Summary Financial Position
Overall financial position as at 31st October 2016 (Month 07)
Year to Date Forecast Outturn Budget Actual (Under)/Over Annual Forecast (Under)/Over spend Budget Outturn spend £000 £000 £000 £000 £000 £000
Acute services Acute contracts -NHS (includes Ambulance services) 210,084 211,396 1 358,813 360,730 1,917 Acute contracts - Other providers 8,822 9,468 1 15,402 17,773 2,371 Acute - NCAs 3,479 3,679 0 6,070 6,333 264 Pass-through payments
Sub-total Acute services 222,385 224,544 2,158 380,285 384,836 4,551
Mental Health Services MH contracts - NHS 45,727 46,276 549 78,389 79,082 692 MH contracts - Other providers 2,127 2,362 235 3,949 4,345 396
Sub-total MH services 47,854 48,638 784 82,338 83,427 1,089
Community Health Services CH Contracts - NHS 54,872 55,124 252 94,996 95,435 439 CH Contracts - Other providers (6,721) (6,826) (105) (11,471) (11,581) (110) CH - Other
Sub-total Community services 48,150 48,298 147 83,526 83,854 329
Continuing Care Services Continuing Care Services (All Care Groups) 10,768 11,709 940 19,141 20,099 958 Local Authority / Joint Services 1,442 938 (504) 2,472 1,608 (864) Free Nursing Care 5,200 6,475 1,275 8,914 11,545 2,631
Sub-total Continuing Care services 17,410 19,121 1,711 30,527 33,252 2,724
Primary Care services Prescribing 55,585 55,049 (536) 95,965 95,128 (837) Co-Commissioning and Enhanced services 48,851 48,393 (458) 84,150 83,782 (368) Other 7,092 7,005 (87) 11,321 11,217 (104)
Sub-total Primary Care services 111,528 110,447 (1,081) 191,435 190,127 (1,309)
Other Programme services Other 16,319 16,344 25 28,068 28,143 75
Sub-total Other Programme services 16,319 16,344 25 28,068 28,143 75
Total - Commissioned services 463,646 467,392 3,746 796,179 803,639 7,459
Specific Commissioning Reserves 5,799 2,241 (3,558) 16,673 9,347 (7,326) (Inc headroom and Contingency) Total - Programme Costs (excl Surplus) 469,445 469,633 188 812,852 812,986 134
Running Costs (incl reserves) 7,912 7,724 (188) 13,563 13,429 (134)
Total - Admin Costs (excl Surplus) 7,912 7,724 (188) 13,563 13,429 (134)
Surplus 5,516 0 (5,516) 9,456 0 (9,456)
Total Application of Funds 482,873 477,357 (5,516) 835,871 826,415 (9,456) NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP Appendix 4 QIPP Programme 2016/17
Planned Gross Recurrent Forecast Variance Theme Savings Theme Savings / Trend £'000 £'000 RAG RAG 2015/16 RAG £'000 Urgent Care 6,136 5,553 (583) A A A Planned Care 6,435 4,232 (2,203) A A A Community 1,050 1,348 298 G G G Prescribing 4,420 3,795 (625) A A A Transactional 0 0 0 A A A Unidentified 0 0 0 Grand Total 18,042 14,929 (3,113) Additional Schemes 0 n/a n/a n/a Additional QIPP / Slippage / Contingent resources / Application 3,113 3,113 of QIPP rule Grand Total 18,042 18,042 0 Appendix 6 NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP Cash Performance Indicators
As at 31st October 2016 (Month 07)
Actual/Forecast Charges in Month
Advance CHC inc Risk CASH CASH AT Drugs Co pool Capital TOTAL TOTAL LIMIT MONTH % CASH LIMIT Bal/Cash Drawn Prescribing Home Oxygen Payments Commissioning contribution Allocation MONTH YTD 1/12ths END DRAWDOWN Limit Month Status £000 £000 £000 £000 £000 £000 £000 £000 % % April Act 75,000 6,742 87 (175) 462 82,116 82,116 68,758 9.95% 0.00% May Act 62,000 6,836 85 28 68,949 151,065 137,516 6,181 18.31% 0.75% June Act 67,000 7,261 84 (35) 74,310 225,375 206,273 14,793 27.32% 1.79% July Act 59,000 6,826 85 20 65,931 291,306 275,031 14,595 35.31% 1.77% August Act 52,000 7,078 86 123 59,287 350,593 343,789 6,291 42.49% 0.76% September Act 57,000 6,943 89 (137) 63,895 414,488 412,547 1,136 50.24% 0.14% October Act 64,000 6,826 86 25 70,937 485,425 481,304 2,313 58.83% 0.28% November F'cast 64,000 6,826 84 70,910 556,335 550,062 67.43% 0.00% December F'cast 60,278 6,826 86 67,190 623,525 618,820 75.57% 0.00% January F'cast 60,278 6,826 86 67,190 690,714 687,578 83.71% 0.00% February F'cast 60,278 6,826 86 67,190 757,904 756,335 91.86% 0.00% March F'cast 60,278 6,826 86 67,190 825,093 825,093 100.00% 0.00%
Proportion of Cash Limit Utilised Actual and Forecast 900,000 800,000 700,000 600,000 500,000
£'000 400,000 Cash used YTD 300,000 Cash Limit 200,000 100,000
0
July
May
June
April
March
August
January
October
February
December
November September
Overview of current position
At the end of October £485m had been drawn down (58.8%) of the anticipated cash limit against 58.3% on a straight line basis. Appendix 6 NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP
Performance against better payment practice code Reported Performance (£) As at 31st October 2016 (Month 07)
In Month Year to Date NHS Non NHS NHS Non NHS By volume Total number of invoices 316 1,144 2,094 7,836 Number paid within target 316 1,106 2,074 7,637 Performance 100.00% 96.68% 99.04% 97.46%
By value Total value of invoices (£'M) 15.38 5.60 153.86 34.50 Value paid within target (£'M) 15.38 5.59 153.79 33.99 Performance 100.00% 99.82% 99.95% 98.52%
The target performance level is 95%
%age Performance by value 100%
95%
90%
85%
80%
75%
70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
NHS1 Non NHS1 Target Performance
%age Performance by volume 100%
95%
90%
85%
80%
75%
70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
NHS Non NHS Target Performance Appendix 7 NHS GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUP
Statement of Financial Position
As at 31st October 2016 (Month 07)
Opening Current Forecast Position as at Month end Position as at 31 March 2016 Position 31 March 2017 £000 £000 Non-current assets: Premises, Plant, Fixtures & Fittings 290 242 206 IM&T 0 0 Other 0 0 Long Term Receivables 0 0 Total non-current assets 290 242 206 Current assets: Inventories 0 0 Trade and other receivables 7,238 11,855 6,000 Cash and cash equivalents 23 2,313 1 Total current assets 7,261 14,168 6,001
Total assets 7,551 14,410 6,207
Current liabilities Payables (43,221) (42,324) (40,000) Provisions (1,782) (1,471) (300) Borrowings 0 0 Total current liabilities (45,003) (43,795) (40,300)
Non-current assets plus/less net current assets/liabilities (37,453) (29,385) (34,093)
Non-current liabilities Trade and other payables 0 0 Other Liabilities 0 0 Provisions 0 0 Borrowings 0 0 Total non-current liabilities 0 0
Total Assets Employed: (37,453) (29,385) (34,093)
Financed by taxpayers' equity: General fund (37,452) (29,385) (34,093) Revaluation reserve Other reserves Total taxpayers' equity: (37,452) (29,385) (34,093)
Agenda Item 10
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Gloucestershire Sustainability and Transformation Plan (STP): Update Paper Executive Summary This paper provides a further update from the September STP Board Paper. Further refinements have been made in preparation of publication which occurred on 11th November. The Short Guide has also been attached.
Key Issues Public response towards STP Ensuring alignment between the STP submission and Operational Plan 2017- 19 Risk Issues: The main risks currently inherent in the Original Risk development of the STP are still present. This Residual Risk consists of the capacity and capability of programme and project teams to deliver and the challenge of developing a shared resources plan for Gloucestershire. Financial Impact The STP sets out a system wide resources plan for Gloucestershire until 2020. Boards should note that this is the final STP plan and short guide which has now been published. Legal Issues (including The STP includes a commitment to ensure NHS Constitution) compliance with NHS Constitution Standards and meet the requirements set out in the national planning frameworks. Impact on Health The STP includes a clear commitment to Inequalities reduce health inequalities. Impact on Equality and The STP includes a commitment to ensure Diversity equality, value diversity and therefore, there will be a net positive impact as a result of developing and implementing the plan. An equality impact assessment will be completed for the STP. Page 1 of 5
Impact on Sustainable The STP supports sustainable development. Development Patient and Public Patients and the public are involved in Involvement developing the STP through the work done on Joining Up Your Care. Patient and public representatives are engaged through the stakeholder events planned as we develop the STP.
Recommendation The Governing Body is asked to:
note the final Gloucestershire STP plan, which is now in the public domain alongside the Short Guide and Survey; and note revised Governance Structure and Memorandum of Understanding (MOU). Author Ellen Rule Designation Director of Transformation and Service Redesign Sponsoring Director As above (if not author)
Page 2 of 5
Agenda Item 10
Governing Body
Thursday 24th November 2016
Sustainability and Transformation Plan Update
1 Introduction
1.1 Gloucestershire is working to a local footprint for the STP. Our system submitted a second draft of our STP Plan on 21st October 2016 to NHS England and published our plan on 11/11/2016.
1.2 Our STP has brought together the health and care leaders in Gloucestershire to drive the delivery of improved health and care based on the needs of our local population. Together we have identified the areas that we believe can be transformed by working together in a new way, driving genuine and sustainable transformation in patient experience and health outcomes over the longer-term.
1.3 Our STP framework does not replace existing local bodies, or change local accountabilities - it is a shared endeavor to work together and improve future care, and this plan does not seek to capture everything we do every day in our health community to improve care. What it describes are the areas where we have agreed that working together is in the best interests of our county, and where we believe the biggest step changes can be achieved.
2 STP Publication
2.1 The STP Plan and accompanying Short Guide and Survey were published on 11th November 2016. This can be found online by visiting: www.gloucestershireSTP.net
3 Communication and Engagement
3.1 A communication and engagement strategy and plan has been developed to support the STP approach, to ensure comprehensive and planned engagement and communication with interested parties Page 3 of 5
throughout the life time of the programme. The plan is owned by a working group, which has been set up to include all of the Communications and Engagement leads of the STP partners, who will continue to embed and develop the plan.
3.2 In preparation to publication of the full STP plan, various materials have been developed to ensure key messages are consistent across the system. Support has been provided to all senior members at partner organisations in the form of media and stakeholder briefings. A media schedule has also been produced to ensure appropriate engagement takes place in the preceding week(s) to publication.
4 Governance
4.1 Our system has agreed a collaborative leadership approach for our STP, with system leaders taking ownership of key STP work programmes on behalf of partners across Gloucestershire. The governance structure has been updated to reflect the role of Gloucestershire Strategic Forum and amendment to the STP Stakeholder Group, formerly the Oversight Board.
4.2 A Memorandum of Understanding (MOU) has been agreed by all organisations to support the delivery of STP across the system. The MOU sets out the way we have agreed to work, confirming the approach of sharing risk, information sharing and governance and clinical governance to support integrated working. Recent changes have been made to this document therefore the final version has been attached for formal sign off.
5 Planning Round
5.1 The Operational Plan (2017-2019) will provide a commissioning perspective on how to deliver years 1 & 2 of the STP Plan. The review of progress against the CCG’s 2016/17 Operational Plan has been used to inform the first draft narrative as well as alignment to the 9 national must do’s. The Operational Plan will be a vehicle to support the delivery of our STP objectives therefore will be closely aligned. All contracts will be agreed by the end of December 2016.
The development of the narrative will have oversight and sign off by the Director of Strategy and Transformation.
Page 4 of 5
6 Recommendations
6.1 The Governing Body is asked to:
note the final Gloucestershire STP plan, which is now in the public domain alongside the Short Guide and Survey (attached); and note revised Governance Structure and MOU (attached).
Page 5 of 5
Annex 1 - STP Plan
1 Contents The One Gloucestershire Challenge...... 3 Our Plan on a Page:...... 6 Chapter 1: The Gloucestershire Context...... 7 1.1 Our Vision and Values:...... 7 1.2 Gloucestershire Facts and Figures:...... 8 1.3 Gloucestershire’s Health and wellbeing Gap...... 10 1.4 Gloucestershire’s Care and Quality Gap...... 11 1.5 Gloucestershire’s Finance and Efficiency Gap:...... 13 Chapter 2: Our Delivery Priorities...... 15 2.1 Enabling Active Communities...... 16 2.2 One Place, One Budget, One System...... 18 2.3 Clinical Programme Approach...... 22 2.4 Reducing Clinical Variation...... 25 Chapter 3: Our System Development Programme...... 27 3.1 Organisational Development...... 27 3.2 Quality Academy...... 27 3.3 STP Programme Development and Governance Models...... 28 Chapter 4: Our System Enablers:...... 29 4.1 Joint IT Strategy...... 29 4.2 Primary Care Strategy...... 29 4.3 Joint Estates Strategy...... 30 4.4 Joint Workforce Strategy...... 31 Chapter 5: Impact of Change...... 32 5.1 Financial impact...... 32 5.2 Delivery Impact...... 35 Chapter 6: Implementation...... 37 6.1 Communications and Engagement Strategy and Plan...... 37 6.2 Delivery Plans and High Level Timeline...... 39 6.3 Delivery Risks...... 40 Supporting Documents and Useful Links...... 42 Annex A: Building and Governing the Plan...... 43 A.1 Principles of the Plan...... 43 A.2 Working Together for Gloucestershire...... 44 Annex B: Engaging with our Communities...... 45 Annex C: Enablers...... 46 C.1 Workforce Strategy...... 46 Annex D: Local Assessment against NHS England 10 Big Questions...... 49 Annex E: Plans on a Page...... 52
2 The One Gloucestershire Challenge
”Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Constitution of the World Health Organization as adopted by the International Health Radical Self care Conference, New York, 19-22 June, 1946 and Prevention In October 2014, the Chief Executive of the NHS, Simon Stevens Plan published a compelling vision and strategy for the NHS, the Five Year Forward View. The vision described the opportunities and challenges facing the Pathway NHS for the future, expressed as three key ‘gaps’: The Health and Redesign, Wellbeing Gap, the Care and Quality Gap and the Finance and Respiratory and Efficiency Gap. Dementia This is our local 5 year Sustainability and Transformation Plan (STP) for Gloucestershire. It describes our vision for how publically funded health and social care services can support a healthier Gloucestershire, Clinical that is socially and economically strong and vibrant. Through delivery Variation: of this plan, we believe we can achieve an improved and more Medicines and sustainable health and care system. Diagnostics Our plan will help us meet a number of major challenges: •• A growing population with more complex needs – in Urgent Care Gloucestershire, it is estimated that 47,500 people over the age of Redesign and 65 are living with a long term condition. This is projected to rise to 77,000 by 2030 30,000 community model •• Increasing demand for services and rising public expectations, coupled with low levels of personal responsibility in some areas over personal health and care and a lack of ownership over personal health planning •• Innovation in new medical technology and medicines, which has Place Based the potential to improve lives for many people but needs funding Commissioning for implementation •• Even with a degree of government investment in the NHS, and using the social care levy locally, the pressures far outstrip this funding leaving us with a financial gap of £226m over four years unless we make radical changes to the way we deliver services and Primary Care provide support for local people Strategy •• Strengthening Mental Health Care and Support •• Significant pressures on our NHS and Social Care workforce capacity, with the potential for gaps to arise in key roles unless joint action is taken to develop new roles and ways of working Shared Enablers, IT, What do we want to achieve and how can it be done? Estates and Our long-term ambition is to have a Gloucestershire population, Workforce which is: •• Healthy and Well – people taking personal responsibility for their health and care, and reaping the personal benefits that this can bring. A consequence will be less dependence on health and social care services for support
3 •• Living in healthy, active communities and benefitting from strong networks of community services and support •• Able when needed, to access consistently high quality, safe care in the right place, at the right time. We believe that in order to deliver this ambition, we need to stay true to the principles set out in our ‘Joining up your Care,’ programme which was shaped by local people. However, it is clear that if we are going to meet the growing challenges set out above, more of the same will not do. We are going to have to accelerate the pace of change and be even more ambitious and innovative in how we organise services and use money and other resources available to us.
Moving forward we will need to: •• Place a greater focus on personal responsibility, prevention and self-care, supported by additional investment in helping people to help themselves •• Place a greater emphasis on joined up community based care and support, provided in patients’ own homes and in the right number of community settings, supported by specialist staff and teams when needed •• Continue to bring together specialist services and resources where possible. We will also reduce the reliance on inpatient care (and consequently the need for bed based services) across our system by redesigning our models of care in order to provide services more efficiently and effectively in future •• Offer much greater potential to support people locally, within and connected to their community by creating 16 health and social care communities based around clusters of existing GPs and the county’s market towns; this will require fewer referrals to acute hospitals and specialist services •• Developing new roles and ways of working across our system to make best use of the workforce we have, and bring new people and skills into our delivery system to deliver patient care Looking ahead, we believe that by all working together in a joined up way as ‘One Gloucestershire’, there is an opportunity to build stronger, healthier and happier communities and transform the quality of care and support we provide to all local people.
However, the size of the challenge is great and we can’t do it alone. First and foremost we need people in Gloucestershire to want to do this with us. We will need to work in collaboration with all our community partners, statutory and otherwise to develop our detailed proposals for change. Achieving a state of ‘health’ for people in Gloucestershire and providing high quality care and safe services when they are needed must remain our priorities throughout.
4 Signed: Mary Hutton – Accountable Officer, Gloucestershire Clinical Commissioning Group Dr Andy Seymour – Clinical Chair, Gloucestershire Clinical Commissioning Group Paul Jennings – Chief Executive, Gloucestershire Care Services NHS Trust Deborah Lee – Chief Executive, Gloucestershire Hospitals NHS Foundation Trust Peter Bungard – Chief Executive, Gloucestershire County Council Shaun Clee – Chief Executive, 2gether NHS Foundation Trust Ken Wenman – Chief Executive, South Western Ambulance Service Foundation Trust
Acknowledgments:
This STP plan has been produced on behalf of the Gloucestershire system and contains the contributions, feedback and inputs of many colleagues from each of the partner organisations. We would like to thank them all for their input and support over many months of the production process.
Lead Author: Ellen Rule, STP Programme Director, Director of Transformation GCCG
Coordinating Editors: Sadie Trout, Head of Planning GCCG & Beth Gibbons, STP Project Officer GCCG
Graphics Support: Fiona Leppard, Graphic Designer GCCG
5 Our Plan on a Page:
STP Gloucestershire: Joining Up Your Care
System Development Programme Countywide OD Quality STP Programme Governance Strategy Group Academy Development Models
• Prevention and Self Care strategy Enabling Active • Asset Based Community Models Communities • Focus on carers and carer support • Social Prescribing/Cultural Commissioning
• Urgent Care Model and 7 day services One Place, • People and Place – 30,000 community model One Budget, • Devolution and integrated commissioning One System • Personal Health Budgets / Integrated Personal Commissioning
• Transforming Care: Respiratory and Dementia Clinical Health Gap and Wellbeing • Clinical Programme Approach developing Programme pathways and focus on prevention
Approach Gap Quality and Care • Delivering the Mental Health 5 Year Forward View
• Choosing Wisely: Medicines Optimisation Reducing Gap ciency Effi and Finance Clinical • Reducing clinical variation Variation • Diagnostics, Pathology and Follow Up Care
System Enablers Joint IT Primary Care Joint Estates Joint Workforce Strategy Strategy Strategy Strategy
6 Chapter 1: The Gloucestershire Context
1.1 Our Vision:
Vision: “To improve health and wellbeing, we believe that by all working better together – in a more joined up way – and using the strengths of individuals, carers and local communities, we will transform the quality of care and support we provide to all local people”
Our shared vision was developed through extensive public engagement and set out in the strategy ‘Joining Up Your Care’ in 2014. We believe that the NHS and social care in Gloucestershire is in good shape to move forward, but that there remain significant opportunities for a new conversation with people in our county and for organisations to work together to ensure a sustainable future for health and social care in our county.
In October 2014 Simon Stevens published a compelling vision and strategy for the NHS, the Five Year Forward View. This vision describes the opportunities and challenges facing the NHS for the future, expressed as three key ‘gaps’ – and urges local health and care communities not to rely on “short term expedients to preserve services and standards” at a time which calls for true leadership and transformational change. Health and social care organisations in Gloucestershire have made a commitment to work together to deliver system level change by working together in four new ways:
Enabling Active Communities – building a new sense of personal responsibility and promoting independence for health, supporting community capacity, and making it easier for voluntary and community agencies to work in partnership with us. Using this approach we will deliver a Self Care and Prevention Plan to close the Health and Wellbeing gap.
One Place, One Budget, One System – by taking a place based approach to commissioning and providing we will deliver best value for every Gloucestershire pound. Our first priority will be to roll out a new Urgent Care provision and develop a 30,000 place based care model through this principle. This will ensure we close the Finance and Efficiency Gap, and move us towards delivery of a new care model for our county.
Clinical Programme Approach – systematically redesigning pathways of care, building on our successes with Cancer, Eye Health and Musculoskeletal redesign, challenging each organisation to remove barriers to pathway delivery. Year one will focus on delivery of new pathways for Respiratory Disorders and Dementia and progress the Mental health Task Force recommendations to help us close the Care and Quality Gap.
Reducing Clinical Variation – elevating key issues of clinical variation to the system level to have a new joined up conversation with the public around some of the harder priority decisions we need to make. Our initial priorities will be to deliver a ‘Choosing Wisely for Gloucestershire’ Medicines Optimisation programme and undertake a Diagnostics Services Review. This programme will turn the dial for our system to close the Care and Quality Gap.
We have also committed to work together on the following system enablers:
•• Primary Care Strategy: a sustainable future for primary care in Gloucestershire •• Gloucestershire Local Digital Roadmap: joint IT Programme setting out digital roadmap delivery •• One Gloucestershire Workforce, OD Programme and shared Quality Academy •• One Gloucestershire Estates Strategy: one approach to the public sector estate
7 1.2 Gloucestershire Facts and Figures: Footprint •• 2,653 km2 Facts •• one upper tier, six lower tier local authorities are projected •• 2016 resident population of 618,2001 TEWKESBURY
•• registered population of 635,481 across STOW-ON-THE-WOLD 81 GP Practices and seven GP Localities CHELTENHAM GLOUCESTER •• 71% population concentrated in NORTHLEACH urban areas of mainly Gloucester and Cheltenham STROUD
•• 29% population in rural areas CIRENCESTER FAIRFORD NAILSWORTH LECHLADE ON THAMES •• Increasing diversity within the DURSLEY population •• Deprivation lower than average, but spread in pockets across the county •• Age structure older than England 75 to 84 year olds set to increase by almost 20% by the end of 20/21 Most deprived quintile in England Sustainability and Transformation Plan area Second most deprived Lower Tier Local Authority Average deprived Upper Tier Local Authority •• 85 and over group set to increase the Second least deprived Clinical Commissioning Group fastest in the future Least deprived quintile in England © Crown Copyright and database rights 2016, Ordnance Survey 100016969 Health •• Health of people in Gloucestershire is Outcomes better than the England average Gloucestershire STP
•• Life Expectancy at Birth – higher than 95+ England average 90 to 94 85 to 89 •• Healthy Life Expectancy at Birth for 80 to 84 males has been declining since 2010 75 to 79 70 to 74 •• Life expectancy at 65 years better 65 to 69 60 to 64 than the England average for both 55 to 59 genders but not improving in line with 50 to 54 the national experience, especially for 45 to 49 40 to 44 females. 35 to 39 30 to 34 •• The major causes of death are cancer, 25 to 29 cardiovascular and respiratory problems 20 to 24 15 to 19 •• People with severe Mental Health needs 10 to 14 die 15-20 years earlier 5 to 9 0 to 4 3 2 1 0 0 1 2 3 Wider •• ‘School Readiness’ (a key measure of Males % Age Females % Determinants early years development across a wide Age 2015/16 Five year change (2020/21) range of developmental areas) is an area of poor performance 0 to 14 103,887 5.3%
•• Children from poorer backgrounds 15 to 44 228,279 -0.7% including children in care are more at risk of poorer development and health 45 to 64 174,782 1.5% outcomes. The evidence shows that differences by social background emerge 65 to 74 69,965 4.4% early in life 75 to 84 40,541 19.7%
•• Other areas of focus for us include Fuel 85 plus 18,027 18.3% Poverty2 and Social Isolation Source: ONS England -10 0 10 30 50
1 ONS 2012-based sub-national population projections 2 There is compelling evidence that the drivers of fuel poverty (low income, poor energy efficiency and energy prices) are strongly linked to living at low temperatures (Wilkinson et al 2001) and the recent Marmot Review Team report showed that low temperatures are strongly linked to a range of negative health outcomes. 8 Focus for •• Excess weight in 4 – 5 year olds health improvement •• Smoking prevalence at age 15 years – occasional smokers •• Successful completion of drug treatment for opiate and non-opiate users •• Admissions for alcohol-related conditions (persons and females) •• Access to diabetic retinopathy screening •• Cumulative percentage of the eligible population aged 40-74 who received an NHS Health Check Health •• Population vaccination coverage for flu for older people aged 65 years and over, as well as for Protection, at risk individuals Healthcare and •• Mortality from communicable diseases (persons, males, females) Premature •• Suicide rate (persons, males) Mortality •• Excess winter deaths index - single year, age 85+ (males) Health •• Give every child the best start in life: child poverty levels in the county are much better than Inequalities England average, thereby increasing healthy life expectancy •• Enable all children, young people and adults to maximise their capabilities and have control over their lives: Young people who are not in education, employment or training (NEET) are at greater risk of a range of negative outcomes. The county has historically done well in terms of NEETs (better than England) as well as adults with learning disabilities in employment. The gap in employment rate between those with a learning disability and the overall employment rate has recently increased following a downward trend, especially for females •• Create fair employment and good work for all: Overall Gloucestershire does well in terms of employment. •• Ensure healthy standard of living for all: Work on wider determinants of health •• Create and develop healthy and sustainable places and communities •• Strengthen the role and impact of ill-health prevention: Prevention and implementation of Self-Care Plan Social Care •• Enable people to live independently, in their community, for as long as possible. •• Safeguard vulnerable adults. •• Reduce the number of people in residential care. •• Increase accessibility to home care •• Support carers so they can continue in their role. •• Improve the quality of information, guidance and advice to enable people to make informed choices
9 1.3 Gloucestershire’s Health and wellbeing Gap
The three leading causes of death for our population are cancer (27.9%), cardiovascular disease (26.8%) and respiratory disease (14.2%). Age is the leading risk. The burden of disease in these categories is associated with four additional key risk factors: poor diet, physical inactivity, smoking and excess alcohol consumption. Poor mental and emotional wellbeing also have a key part to play. Gloucestershire is broadly in line with national and regional benchmarks for alcohol related admissions to hospital, levels of physical activity and adult excess weight, although some districts have worse rates than the county as a whole, notably in the west of the county in the Forest of Dean, Gloucester and Tewkesbury. Smoking rates in Gloucestershire are steadily declining and are lower than comparators. Work is underway to capture the impact of loneliness and social isolation as both are factors in worse health outcomes through adding a depression / mental health dimension to needs. Whilst healthy life expectancy for women is almost two years better than for their regional counterparts, the average for Gloucestershire men is lower than for the South West as a whole.
Our ageing population, changing patterns of disease (more people living with multiple long-term conditions) and rising public and patient expectations mean that fundamental changes are required to the way in which care is delivered in our county. We will more fully involve individuals in their own health and care by making shared decision-making a reality by intensively training our clinicians to give people the support and information they need for effective self-management, and involving their families and carers to support them in making the changes needed to keep healthy. Evidence is clear that most people want to be more involved in their own health, and that when they are, decisions are better, health and health outcomes improve, and resources are allocated more efficiently.
To deliver change we will build on our existing collaborations between the NHS, local government, the third sector, employers, Local Enterprise Partnership, Police & Crime Commissioner, Constabulary and others. This is evidenced in our delivery of Social Prescribing as a partnership between all of these partners and our new initiatives to tackle workplace health with our local LEP being developed for delivery in 2016/17. The following prevention opportunities have been identified as having the highest potential significant impact in our county: •• Decrease the incidence and prevalence of colorectal cancer •• Reduce diabetes prevalence (17+) •• Providing people with common mental illnesses with better support •• Increase detection of hypertension and Coronary Heart Disease •• Reduce the prevalence of Asthma •• Increase Flu vaccine uptake by children and pregnant women •• Decrease percentage of low birth weight babies •• Decrease the percentage of children aged 4-5 who are overweight or obese •• Increase the percentage of children receiving MMR vaccine by age 5 •• Reduce the number of decayed, filled or missing teeth in children aged 5 years •• Increase proactive care for those with complex needs 55+ and for babies, children and their mothers, particularly those with circulatory, cancer and gastrointestinal problems •• Improve targeted support for those whose medications may increase their risk profile
10 1.4 Gloucestershire’s Care and Quality Gap
Our assessment of the Care and Quality Gap considers a wide range of indicators and data sets at a national and local level. This includes Right Care; Commissioning for Value, The Atlas of Variation in Healthcare, measures of our local performance delivery and our learning from the reviews of our services conducted by national bodies including the Care Quality Commission. Our key findings are set out below: Top range •• Percentage of deaths which take place in hospital is higher than it should be indicators: •• People with a long-term condition need to feel more supported to self-manage their conditions •• More Injuries from falls in people aged 65 and over per 100,000 population •• Poorer Quality of life of carers as measured by the health status score EQ5D Areas of focus Source: PHE, Right Care, NHS England. Commissioning for Value: Where to Look. January 2016. NHS Gloucestershire identified by The national Right Care Programme identifies the potential savings for each health community Right Care if care was delivered in line with the most efficient areas in the country. This table shows the opportunities identified through the Right Care Programme for Gloucestershire: Savings (£000s) Programme Area Elective admissions Non-elective admissions Prescribing Total 1 Cancer 733 1840 411 2984 2 Neurological 709 654 1363 3 Circulation - 2078 1077 3155 4 Respiratory 173 1132 686 1991 5 Gastrointestinal 435 415 - 850 6 Musculoskeletal 1424 541 - 1965 7 Trauma and Injuries 1774 918 95 2787
Specific •• Cancer and tumours: increasing detection of breast cancer at an early stage, increasing Improvement screening uptake, improving mortality, increasing lung cancer detection Opportunities •• Endocrine, nutritional and metabolic problems: uptake of retinal screening – Cost and Quality •• Circulation problems: improve proportion of stroke patients spending 90% of their time in hospital on a Stroke Unit, reducing premature mortality from all circulatory disease, increasing proportion of patients returning home after treatment •• Respiratory: reducing premature mortality from bronchitis, emphysema and Chronic Obstructive Pulmonary Disease, Increasing the proportion of asthma patients with annual reviews, reducing asthma emergency admission rates for children, increasing the proportion of COPD patients with a record of their respiratory function •• Gastrointestinal: reducing emergency admissions for alcohol-related liver disease, reducing premature mortality from gastro-intestinal and liver disease •• Musculoskeletal problems: improving Patient Reported Outcome Measure (PROM) – for hip replacement and knee replacement •• Trauma and Injuries: reducing mortality from accidents, increasing proportion of patients with a fractured neck of femur returning home in 28 days, reducing hip fracture emergency readmissions within 28 days, reducing mortality for hip fracture •• Genito-urinary problems: especially renal conditions with high first outpatient attendances and increasing the proportion of patients accessing transplants •• Mental health problems: psychosis pathway, Improving Access to Psychological Therapies (IAPT) Pathway and reducing need for out of area treatments •• Children: reducing the emergency admission rates for children under 1 for gastroenteritis and lower respiratory tract infections for children under 5
11 Complex •• The 2% most complex patients in Gloucestershire were responsible for 14.9% (£32,112,000) Patients of the total CCG spend in 2015/16 •• 12.4% of patients had more than 5 A&E attendances (less than peer group average) •• 68% of people using our outpatients attended more than 5 times, 43% more than 10 times and 28% more than 15 times with all frequencies higher than peer average •• The top five conditions for outpatient attendances were cancer, trauma and MSK, circulation, vision and genito-urinary conditions. •• Use of NHS Resources increases significantly for patients aged 55 years and over •• Resources use is also significant for children aged 10 -14 years and babies and toddlers Parity of •• People experiencing mental illness often experience many social determinants e.g. poverty, Esteem social isolation, discrimination, abuse, neglect, drug and alcohol dependencies, leading to poor health outcomes •• Medications used to treat physical illness can have side-effects that produce psychiatric symptoms, and medications used to treat mental illness needs can affect physical health. •• There are higher rates of unhealthy behaviours amongst people with mental health needs i.e. smoking and use of alcohol or other substances •• There are barriers to accessing support relating to stigma, prejudice and discrimination Constitution •• Local delivery of NHS Constitution measures is significantly challenged in the following Delivery key areas: IAPT (Primary Care Psychological Therapy Service) Performance, A&E 4hr wait performance, cancer waiting times CQC Ratings •• The vast majority of Primary Care assessments completed so far all rated as good or outstanding 2 •• G: Inspection Oct 2015 overall good. Outstanding for crisis, home treatment and place of safety, adult inpatient wards and Psychiatric Intensive Care Unit. Two areas required improvement 1) wards for people with LD or autism, all domains except caring require work, 2) Community based Mental Health services for older people: effective and well-led require improvement. Long stay /rehab Mental Health wards and community services for working age adults, Mental Health wards for older people require improvement in the safe domain only •• GHFT: Inspected in March 2015 with outcome of requires improvement especially in the care of patients in the Emergency Department, where excessive waits were experienced. A review of the emergency pathway was required and staffing levels were highlighted. The Trust received outstanding for the critical care areas and good for well-led. •• GCS: Inspected in June 2015 with outcome of requires improvement, issues raised with unregistered practitioners in MIIU undertaking tasks such as triage; long waiting times for therapies and the need to develop an end of life strategy. The Trust were given outstanding for caring in the community hospitals •• SWASFT: Inspected in June 2016 overall ‘requires improvement’. Issues raised with aspects of safety with regard to incident reporting and adherence to Trust policies, procedures and protocols, and effective services. Rated ‘outstanding’ for caring and ‘good’ for responsiveness. Primary Care •• Workforce: 40% of all practices are carrying GP vacancies, 75% are partners. 56% have impending GP retirements,. •• Quality, IT and Transformational Change: improving access at evening and weekends, more on-the-day urgent appointments Patient Safety •• Antimicrobial Resistance: use of anti-microbials in the county are recognised as already being lower than many other areas. The county-wide antimicrobial group continue to target those areas where improvements can be made •• Winterbourne View: The resettlement of LD patients continues to be a high priority with a clear action plan being successfully implemented •• Francis Report: We are committed to achieving the safe staffing levels and have recruitment initiatives to improve staffing and reduce the use of agency staff •• We are committed to ‘Sign up to Safety’ and through a county-wide patient safety forum are working to reduce harm to patients whether in hospital or at home 12 1.5 Gloucestershire’s Finance and Efficiency Gap: In 2016/17 the Gloucestershire STP footprint has faced some financial challenges, with an emergent deficit at Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) impacting on the starting position for our STP plan. The scale of the challenge for our system is derived from analysis comparing future funding growth compared to demographic change, the rising burden of disease, managing local government funding settlements and the ongoing health efficiency requirements. The collective challenge over the life of our STP plan if no mitigating actions or efficiencies are delivered for health and social care is expected to be £226 million.
Our approach to modelling the gap has worked forward from the expenditure requirements of our STP partner organisations and the values set out in the national planning assumptions for expected areas of increasing costs. These include pay, pensions, drugs and nationally mandated programmes such as the implementation of 7 day services and new investment for primary care. Opportunities for our community to work together on closing this gap will look to ways to make cashable savings through delivering technical and structural efficiency, alongside increasing allocative efficiency though ensuring the effective use of health care resources to meet available needs. Alongside ensuring efficiency, our system will support people and communities to live healthier lives to ensure we can reduce increasing demand. The system is working together on a shared plan for all the savings expressed in this plan, however, initially in recognition of the existing organisational accountabilities in place these will continue to be expressed through the currencies of provider Cost Improvement Plans (CIP) and system wide transformation plans. A joint approach has been taken to understand the impact of planned local authority savings which are modelled from both a commissioning and provider perspective Gloucestershire STP Financial Gap without2020/21 mitigations: financial gap without mitigations
Provider Efficiency Provider Cost PressuresReductions to Local GovernmentSpecialist CommissioningFunding CCG Increased activity growth Demand National funding policy pressuresGHFT (CCG) Financial Gap 2020/21 Do nothing
(50)
70m (100) 12m
36m (150) 22m
Forecast deficit £m 29m (200) 30m
(250) 27m 226m
13 Financial Gap: Through the STP, the system has come together to agree a clear plan to managing the delivery of our financial plan that will ensure that there are true savings for the community without just moving activity and cost around between STP partners whilst also ensuring the continued availability of safe, sustainable services in the future.
Gloucestershire STP Mitigations to close financial gap
System GHFT financial Financial Challenge Provider CIP transformational challenge 250
200
150 £70m £m 100 Forecast mitigation Forecast 50
£129m
£226m £27m
14 Chapter 2: Our Delivery Priorities
Our delivery priorities have been shaped in response to our challenges described in Chapter 1. Our four key approaches to turning the dial over the next five years are described below. These are our top priorities designed to deliver services that meet the needs of our population in the face of constrained resources, and maintain our current financially balanced position. Each is explained in more detail in Chapter 2.
In summary, we will address our challenge by: We have developed an approach ‘One System, One Place, • Radical Self One Budget’ to ensure that everyone in our system ‘owns’ the Care and Gloucestershire pound. This is a new place based commissioning Enabling Prevention Radical Self Care and Prevention Plan Prevention Care and Self Radical Active Plan and provider approach based on our people and place model, and we will use this to support our urgent care design and deliver a Communities 30,000 community model, pooling our resources and expertise across the system to redesign our model of care and ensure we can deliver responsive joined up care for our population when • Place Based they need us. By aligning incentives away from organisations and Commissioning ensuring every part of our system benefits from doing the right • Reset Urgent thing this will support transformational change at scale. One Place, Care and 30,000 One Budget, Community We will join together as system partners in a new working One System Model arrangement supported by a Memorandum of Understanding to work together on Clinical Pathway Redesign, Reducing Clinical Variation and key System Enablers together. Not all of • Reset Pathways this work is new, but the way we will work together to deliver it is. for Dementia and Respiratory We will take a new approach to Enabling Active Communities Clinical • Deliver the to deliver a Self-Care and Prevention Plan at scale, taking the Programme Mental Health conversation beyond traditional health and social care boundaries Approach FYFV and engaging with a whole range of partners in a new way. NHS England asked us to describe how this plan would address ‘10 big questions’ laid out in their planning guidance. A summary • Choosing of our response to their challenge is set out at Annex D to this Wisely document. In return, we are asking NHS England to support Medicines our system to deliver through the following key ‘asks’ which are Reducing Optimisation expanded on through our programme level descriptions: Clinical • Diagnostics Variation Review •• Permission to take a local approach to commissioning our new urgent care offer •• Support at a national level for a new conversation with the • Primary Care public regarding personal responsibility for health and self-care • Joint IT Strategy • Joint Estates •• A national drive and joined up approach to the Choosing System Strategy Wisely programme and prioritisation of health interventions Enablers • Workforce •• Support to develop plans for delegated co-commissioning of specialist commissioning
15 Programme Leaders: Margaret Willcox – Director of Commissioning, Adults (GCC), Linda Uren – Director of Commissioning Children and Families (GCC), Mary Hutton 2.1 Enabling Enabling Active Communities – building a new sense of personal responsibility Active and improved independence for health, supporting community capacity and ensuring Communities we make it easier for voluntary and community agencies to work in partnership with us. We will use this approach to deliver a radical Self Care and Prevention Plan led by Public Health to close the Health and Wellbeing Gap in Gloucestershire. Improving Lives is a core function of the NHS, expressed in the NHS Constitution as the need for the NHS to “help people and their communities take responsibility for living healthier lives”.
Our first year will focus on delivering Social Prescribing and the shared Prevention and Self-Care Plan. We recognise that more systematic prevention is critical in order to reduce the overall burden of disease in the population and maintain the financial sustainability of our system. Our Prevention and Self-Care Programme provides a clear framework and plan for whole system change that will enable patients and communities to take a lead in their health and care. Our aim is to create the conditions for community and individuals to thrive, to remove any barriers and for our services to work to meet the needs and harness the assets of our communities in ways that are empowering, engaging and meaningful.
Self-Care and Prevention Plan delivered by Enabling Active Communities approach 1 Continue to deliver Develop and initiate 2 Support Prevention and Learning from
1
r r Social Prescribing delivery of r Self Care Plan with Yr 1 and 2 to 3-5
Y Y with system partners Prevention and Self Y Social Movement public set priorities r
Care Plan campaign Y
Our approach to prevention will help us to focus on how we remove the barriers to access for people with a range of health inequalities. For example, we will ensure we address how individuals with mental health needs including dementia can be supported in accessing the health prevention screening, planning and interventions, which will be available to the general population. To deliver this, mental health services and patients will help co-design/produce a programme of interventions, and ensure those practitioners and others working in mental health, community/ primary care and voluntary services can facilitate access for those that need focused individual motivation, help and support.
Similar plans are being developed in relation to social inclusion and social reablement programmes, so that individuals with mental health needs are supported into employment opportunities and have access to appropriate accommodation to minimise the impact these factors contribute to their ill health. Progressing these programmes in this way, will contribute to improving the “Parity of Esteem” for people with mental health needs, enabling them to access services that the majority of the public are able to do/enjoy freely.
What is the matter with you?' and 'what matter's to you?' are two “phrases that are increasingly going hand in hand with each other. As how we deliver healthcare is changing, we are becoming less the experts to our patients and more the facilitators and teachers of our patients. A recent example of taking a motivational interviewing approach and asking what mattered to a patient I look after with diabetes resulted in him taking a slimming world referral, losing 2 stone and stopping his two types of insulin and blood pressure tablets. He and his family are very proud of his achievement. Dr Hein Le Roux, Minchinhampton Surgery
16 Through our STP we will work together to: •• Promote healthy lifestyles and self-care: a new conversation with the public through a ‘social movement’ approach focussed on personal responsibility for health and wellbeing •• Promote healthy workplace environments through the Workplace Wellbeing Charter •• Targeted approaches for vulnerable population groups •• Tackle health inequalities through asset-based approaches •• Take a whole system approach to obesity working with Leeds Beckett University and Public Health England •• Ensure appropriate coverage of key secondary prevention interventions that systematically detect the early stages of disease i.e. Diabetes Prevention Programme •• Ensure a strategic approach to the commissioning of self-management support •• Develop our system to support person-led care and personalised care planning i.e. Integrated Personal Commissioning (IPC) •• Utilise the capacity and strengths within our communities through closer working with the Voluntary, Community and Social Enterprise (VCSE) Sector i.e. Social Prescribing •• Ensure substantial involvement of communities and individuals to co-produce local solutions and services i.e. Cultural Commissioning Programme •• Ensure a range of carer services are delivered in line with the Care Act •• Implement innovative technologies i.e. Diabetes NHSE Digital Test Bed •• Increase visibility, awareness and acceptance of Mental Health By 2017 we will have: •• Accredited 40 organisations through the National Workplace Wellbeing Charter •• Rolled out Atrial Fibrillation diagnosis treatment programme with Academic Health Science Network to 60 practices •• Trained 80% of our primary schools to support the implementation of the ‘daily mile’ •• Trained 21 leaders within our Integrated Community Teams to roll out health coaching •• Worked to develop a new integrated healthy lifestyle service to target the top four modifiable lifestyle causes of chronic disease and support self-care •• Built on our investment of £600,000 in Social Prescribing to support over 2500 individuals through our Social Prescribing programme. •• Developed Social Prescribing schemes together with mental health including investment in a Crisis Café •• Developed plans to invest £1.7 million to support implementation of the Prevention and Self-Care Plan •• Worked with Active Gloucestershire to develop ways to increase activity •• Implemented new services for personality disorder, perinatal mental health conditions and developed mental health services for young people under Future in Mind •• Piloted with AHSN the NHSE Digital Test bed on diabetes management By 2021 we will have: •• Stabilised the prevalence of Type 2 Diabetes through the implementation of the National Diabetes Prevention Programme and our whole system approach to obesity •• Adopted the learning from our NHSE Digital Test Bed and developed innovative approaches to support individuals with long-term conditions to self-manage •• Reduced the number of ‘inactive individuals’ by 90,000 through investment in a broad range of physical activity initiatives •• Stronger, more resilient and well-connected communities that lead to better health and wellbeing and a reduction in inequalities •• We will have a personalised care plan for a targeted proportion of patients with one or more long-term conditions having a personalised care plan 17 Programme Leaders: Paul Jennings, Mary Hutton One Place, One Budget, One System – we will take a place based approach to our resources and deliver best value for every Gloucestershire pound. Our first priority 2.2 One Place, will be to redesign our Urgent Care system and deliver our 30,000 community model. We will take a place based commissioning approach to reset urgent and One Budget, community care to deliver efficiently and effectively. This will ensure we close the One System Finance and Efficiency Gap, and move us towards delivery of a new care model for Gloucestershire. Our new care model will be informed by the learning from year one and two of our STP delivery.
Urgent and Emergency Care: When you need to access health care urgently, it’s essential that you get the right response for your needs. Our vision is that this is provided in a range of facilities and locations, but that each of these will have the best expertise and facilities to give you the best chances of a good recovery.
New model of care delivered through One Place, One Budget, One System approach
Develop pilots to Pool urgent care Implement urgent Learning from Yr1 reset the dial for resources in shadow and community care and 2 to set a new Yr 1 Yr 2 Yr 1 Urgent Care system form to take ‘place model at wider scale care model, urgent and 30,000 place based’ Commissioning based on Yr1 and responsive care Yr 3-5 based Community Approach and agree learning, reset resources pooled on Teams county bed model county beds place basis
Sometimes the first step can be self-care and prevention which our ASAP website and App and the NHS 111 phone number can help provide; directing patients to the right service for their needs. Services such as pharmacists may be able to help, or give self-care advice for patients to prevent an illness from getting worse.
Often, the next step would be primary care or a GP. At the moment a patient might call them directly to get an urgent appointment, but in the evening and at weekends their call would link them to a GP out of hours service. We plan to develop an urgent primary care service in key locations throughout the county so that patients access these services 24/7 in a location that’s convenient to where they live.
These Urgent Care Centres in key locations will be the hubs that can link patients to other services. As well as a GP service, they will have other highly trained staff who can further assess what care patients need, order tests and treat a wide range of conditions. Our vision is the majority of patients can access this care within a maximum of 30 minutes driving time.
Of course, some very urgent health problems are life-threatening emergencies, like a heart attack or serious head injury. These will need very specialist care in hospital and would usually be accessed by calling the 999 emergency number for an ambulance.
Our vision for Urgent Care will deliver the right care for patients, when they need it. We plan that it will deliver 7 day services across the county by 2021.
In order to make this vision a reality and provide safe and sustainable services in to the future, we need to consider how to make best use our resources, facilities and beds in hospitals and in the community. We want to improve arrangements for patients to access timely and senior clinical decision making about their treatment and ensure specialist support is accessed as soon as possible.
New Models of Care: Our community care redesign will ensure responsive community based care is delivered through a transformative system approach to health and social care. The intention is to enable people in Gloucestershire to be more self- supporting and less dependent on health and social care services (see self-care and prevention plan), living in healthy communities, benefitting from strong networks of community support and being able to access high quality care when needed in the right place, at the right time. New locality led ‘Models of Care’ Pilots will be carried out during 2016/17 to ‘test and learn’ from their implementation and outcomes to help inform and develop the future model of care for Gloucestershire.
18 These pilots are already testing one system working across organisational el boundaries, with staff accountability to each other as well as to their od Co M m own organisations, giving an opportunity for greater integration # m y ´¶ of health and social care services to support delivery of co- t ´ u i µ ¶ µ ordinated care. The pilots provide an opportunity for clinicians µ # n GPs and # n ¶ µ i to design and implement models of care based upon the ´ ´¶ u Practice# teams Community# ´ t µ ¶ needs of the local population to provide the best outcomes staff from ´ including µ y µ for local people. We are open to the possibility that this ¶ µSocial G.C.S, 2gether# ¶ m # # ´ Prescribing and G.C.C.
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a minimum of 30,000 populations. We are working with our y u t i localities to lead the delivery of place based plans that recognise the n needs of our populations across our varied footprint, taking account of the different delivery models needed in urban vs. rural areas of our county. Work to date has developed our thinking about the future organisation of primary care, with GP surgeries in Gloucestershire proposing to form 16 GP ‘clusters’ from 2017/18. These clusters will enable practices to work together to share skills providing a stronger and more robust primary care service for Gloucestershire.
Design of the pilots will be devolved to locality levels, Pilots: developing a network of learning about how best to Integrated Primary & Community based provide community based services and support. Through Urgent Care this work our primary care clinicians across the system can directly contribute towards a sustainable future Stroud & Berkeley Vale for primary care. We will bring together the learning One Place, One Budget, One System from these pilots through the New Models of Care South Cotswolds – Programme Board. Frailty Primary Care at Scale GP Forward View (countywide)
Fig 1: People and Place model. Our One Place, One Budget, One System My Region Specialist Regional approach to provision and delivery of services will be (2,000,000) Centres enabled by the concurrent development of a place My County based commissioning Specialist Hospitals approach for responsive (600,000) and urgent care, described by our People and Place My District/Locality Model. In 2016/17 Community, (80-100,000) we will set indicative Primary and budgets and share transparently through My Local Area Support the STP how resources (15-30,000) are used across urgent and community care My Village/Suburb Jack services to pave the way (5-10,000) for a new commissioning Me / My approach to enable early implementation in My Street Home (1) 2017/18. (500-1,000)
19 By 2017 we will have: Urgent Care: •• Completed an evidence-based proposal to reshape Urgent Care Pathways within Gloucestershire across hospital and community based services for engagement with our local community. This will start to inform our thinking on a whole county bed model to make best use of resources available across our county and support delivery of 7 day services •• Continued to promote ASAP online to help people identify their symptoms, obtain self care advice, find the nearest relevant services, information on when to use them and to check opening hours. This will be supported by the development of an urgent care digital platform that will ensure 24/7 access to a reliable and robust directory of service for both public and health and social care staff •• Ensured that advice and treatment is available from a network of community pharmacies across our county •• Ensured we have delivered a responsive Mental Health Crisis Service for young people and adults and developed a programme for communities to have local Accredited Mental Health First Aiders and Champions delivering increased visibility, awareness and acceptability •• Provided a consistent approach to the use of National Early Warning Score across our Urgent Care System •• Established a clear Memorandum of Understanding to enable shadow pooling of budgets in a one system approach for urgent and responsive care
New Models of Care: •• Delivered our 30,000 model and community pilots through which we will pilot a number of local clinics to reduce admissions including providing an expanded Community Intravenous Therapy Service •• Commenced implementation of our End of Life Strategy •• Further developed our Social Prescribing offer and integrate Cultural Commissioning Pilots •• Link paramedic practitioners and additional mental health staff to practices and make sure pharmaceutical advisors cover a single cluster •• Agreed our emerging model of 16 GP cluster groups, supporting these to integrate and develop new ways of working, such as developing shared clinical and pharmaceutical policies and back office functions such as shared telephony •• Appointed a Joint Director of Integration to work between health and social care
20 By 2021 we will have: Urgent Care:
•• Developed new ‘Urgent Care Centres’ across localities in a way which allows the majority of patients to access them within a maximum of 30 minutes driving time. These centres will have access to a range of diagnostic services and clinical expertise •• Delivered easier and more convenient access to GP practice services including additional slots for urgent appointments. Primary care in normal working hours will work closely with primary care ‘out of hours’ where patients may receive telephone advice, be seen in their own home or at a local primary care centre and local GPs will play a unique role as ‘conductors’ of urgent care within their locality •• Ensured our urgent care offer is fully integrated, with NHS 111 continuing to be the main route into urgent care services for many patients – with the option to speak to a clinician if needed, and, with your consent, your health records being available to clinicians treating you wherever you are •• Ensured that those people with more serious or life-threatening emergencies are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery •• Ensured that the range of options open to senior decision makers will include services which do not require admission to hospital. These include enhanced ambulatory care (medical care provided on an outpatient basis, including diagnosis, observation, treatment and rehabilitation services) and quick access to ‘hot clinics’ (appointment slots with senior clinicians with priority for urgent cases) •• Ensured when an admission to hospital is needed, that we will start planning discharge home as soon as possible so people do not stay in hospital any longer than absolutely necessary, and so health and social care work together effectively to support safe discharges •• Ensured that our main hospitals provide a range of services 7 days a week in order to meet the agreed national clinical standards •• Commissioned for urgent and responsive care on a new placed based basis, utilising a multiyear whole population budget and contract with effective gain/risk share approach •• Delivered a new countywide bed model making best use of sites and resources, which will include a new approach to rehabilitation across our county
New Models of Care: •• All practices will be working through new networks, sharing ways of working such as shared clinical and pharmaceutical policies and shared/ integrated telephony and IT systems •• ‘Locality Urgent Care Hubs’ established in each area, meeting the particular needs of these local communities – these will provide a focus for urgent care within geographical localities and will include GP, community hospital and other community services working together. As part of this development GP practices will also work together in collaboration to share resources (e.g. to prioritise calls received via NHS 111 or to better co-ordinate home visits)
At last a sensible strategy to put “patients at the centre of care planning. The new STP aims to provide a new localised primary care where social support and medical needs are planned and delivered in a co- ordinated package
Dr Victoria Blackburn, Stroud GP
21 Clinical Programme Approach – We will work Programme Leader: together across our system to redesign pathways Deborah Lee 2.3 Clinical of care, building on our successful delivery to date with Cancer, Eye Health and Musculoskeletal redesign, Programme challenging each organisation to remove barriers to Approach pathway delivery. Our first year will focus on delivery of new pathways for Respiratory and Dementia to help us close the Care and Quality Gap.
Systematic Delivery of Pathways Improvement through Clinical Programme Approach
Complete Deliver new Deliver new Further Implementation of 1 pathways for pathways for programme Yr 1 Yr Eye Health and MSK Yr Respiratory and Circulatory and priorities based on Yr 2 Yr Clinical Programmes Dementia Clinical Diabetes Clinical progress and Right Yr 3-5 Yr and share learning Programmes Programmes Care updates
We will systematically redesign the way care is delivered in our system by reorganising care pathways and delivery systems to deliver right care, in the right place, at the right time. We will build on the strong foundations of the Clinical Programme Approach, strengthening it with a new systems leadership model enabled by our STP to deliver truly integrated pathways. The approach will utilise improvement science, learning from programmes already reaching implementation (Cancer, Eye Health and MSK) and embedding a pro-active approach to preventing Pathway Redesign for Respiratory and Dementia and Respiratory for Redesign Pathway disease, diagnosing earlier and treating and managing the condition from its early stages. We will apply this thinking across all our programme areas, for example the Children’s Clinical Programme Group are focussed on a shift to prevention over a range of areas including promoting resilience and good emotional wellbeing through an earlier identification and support of mental health needs. In the first year of our STP, pathway work in respiratory and dementia will provide a test bed for delivery of truly integrated pathways across our system supported through these principles: •• Resources, including staff, will be aligned to optimum pathways of care reducing duplication and inefficiency. Through this approach the system will work towards upper decile efficiency as benchmarked through the Right Care approach •• Pathways of care will be designed to maximise delivery locally, (utilising the full range of assets in a community, including technology) reducing the dependency on hospital based care, and reducing costs in the system overall •• Clinical teams will feel empowered to change services to make the best use of available resources, working with an agreed integrated clinical governance model •• Patients, carers and the public meaningfully involved using co-production methodology where appropriate in the whole pathway design •• Delivering Parity of Esteem through delivering the Mental Health 5 Year Forward View We will test out an additional focus on ‘Designing for Delivery’, designing and agreeing the supportive governance and funding arrangements between organisations that will support rather than frustrate the delivery of an integrated pathway model.
The learning and evaluation from Respiratory and Dementia within our STP framework will be rapidly evaluated and scaled up to other pathways across our priority programme areas of circulatory disease, conditions impacting on Mental Health, End of Life and Diabetes.
We are looking forward to working more closely with our partners in the county to provide more person “ centred care for people with dementia. Dementia is more common in older people, who often have co- morbid physical health conditions. Their dementia can make their physical health conditions worse, and vice versa. It’s important that we provide a holistic approach to mind and body and that our services wrap around the person, rather than them moving between services themselves. Dementia is everyone’s business and we are keen to ensure that all of our services are working together to provide the best service for people with dementia and their families Dr Martin Ansell, Consultant Psychiatrist for Older People and Clinical Director for Older People’s Services at 2gether NHS Foundation Trust
22 Where pathways interface with other commissioners including specialist commissioning, we will work with them to ensure an integrated approach that works across Evaluation commissioning boundaries with the patient at the centre. Implementation Our early engagement with the Specialised Commissioning team clearly identifies important opportunities for Delivery improvement in a number of pathways but in particular Children and Adolescent Mental Health Service, Forensic Design and Secure, Trauma, Cancer and Chemotherapy, Neurosurgery/Rehabilitation, and Cardiovascular. The key opportunities include integrating pathways, developing local service alternatives and helping to crystallise opportunities for consolidation as part of reconfiguration plans. As outlined in the first part of Chapter 2, our system would like support from NHS England to progress the collaborative commissioning process and set out plans for a delegated commissioning approach to develop through 2017/18 and 2018/19. The working assumption is that any released efficiencies arising from pathway redesign of specialist pathways would be reinvested in the local system for the benefit of patients in Gloucestershire. We have agreed as local STP partners to focus on the cancer programme and during 2017 will scope how a co-commissioning approach can deliver greater service improvement. Where clinical programme design infers that local services would be better supported as part of wider clinical networks we will engage with these networks through the clinical programme group. This is the model we have used through existing programmes, for example the Cancer Clinical Programme Group which provides our connection to the specialist cancer clinical network groups and is now an active member of our local Cancer Network, delivering the national strategy Achieving World Class Cancer Outcomes.
Development of Children and Maternity Services Giving birth is a special time for all women and their families and although there are 6000 births per year each one is uniquely important. In recent years significant progress has been made to improve the quality and safety of services, as well improving choice for women and their overall experience.
During 2016/17 the Gloucestershire Health Community has focussed on delivering the commitments set out in Gloucestershire’s ‘Future in Mind’ Strategy, progressing the response to gaps identified in perinatal mental health care and improvements in paediatric continence and autism pathways. Work is ongoing to review the support available to children who are frequently admitted to hospital and the steps to tackle reducing emergency admission rates for common conditions such as gastroenteritis in children under 1 and lower respiratory tract infections for children under 5.
Improving the experience of our maternity services and the findings of the National Maternity Services Review: Better Births (2016) continue to be key drivers in our approach to improving maternity services in Gloucestershire. Our resulting action plan has seen the revised pathway for unscheduled care for maternity services and highlighted postnatal care as a key area of focus for improvement locally.
By 2017 we will have: •• Implemented a new MSK model for Gloucestershire with clear pathways across our system across primary and secondary care •• Delivered a step change in cancer pathways with a new community based survivorship model in place and a rigorous and innovative approach to cancer case audit reviews in partnership with the Royal College of General Practitioners •• Completed the implementation for our Eye Health Clinical Programme including delivery of new community Eye Health Services •• Through our new STP ways of working we will develop and implement new pathways for Respiratory and Dementia across our system •• Continue to implement the action plan associated with the Better Births Report (2016) to include:
{{ Work with women, families and stakeholders to improve postnatal care
{{ Develop community hubs and integrating better together services that support women and families in the early years including health visiting and children’s services.
23 {{ Implement the action plan relating to Saving Babies Lives, aiming to reduce stillbirths via smoking cessation and monitoring movements and growth of babies.
{{ Continue to develop and implement different ways of engaging women and families in diverse communities in conjunction with Health watch and GHNHSFT through social media and other means.
{{ Work with public health and the new Healthy Lifestyles service to embed pathways of support for women to improve their health and wellbeing. •• Develop an integrated specialist perinatal health service comprising of specialist maternity, infant and adult mental health knowledge and support to ensure that women and families with complex mental health needs consistently receive robust specialist assessment, multiagency planning and support. This will include a skilled workforce that is trained to be able to support women, an increased range of community support options and the development of an anti-stigma campaign. •• Fully implement the paediatric continence action plan to ensure that children’s continence issues are detected as early as possible, with children being supported in the community where possible to ensure the best experience and outcomes. •• Continue to improve transition for young people with long term conditions to ensure that the Ready, Steady, Go Programme is fully embedded.
By 2021 we will have: •• Systematically reviewed key programmes of care across our system, implementing new pathways based on best practice evidence ensuring right care, right place, right time and that patients are offered choice of provider where appropriate •• Improved our elective and urgent care Standardised Admission Ratios (SARs) to ensure we are at or below benchmarks
There have been huge changes over the past few years within the Gloucestershire Health Community. There has been a growing demand on health care resources due“ to the increased prevalence of chronic diseases and a resulting unsustainable pressure upon emergency care in our hospitals. These pressures have resulted in various initiatives by the different health care providers to deliver more sustainable alternatives to the traditional health care model. Whilst these services have often been of high quality they have resulted in a degree of duplication and fragmentation of care. We now need to blur the organisational divides and refocus on patients in order to utilise all of these resources more efficiently and effectively. Patients require that our services work as seamlessly as possible and that care along the clinical pathway is integrated. Our ambition is to develop integrated specialist teams that provide multidisciplinary specialist skills to patients from the home to the hospital and to support pathways from prevention, early diagnosis and through to emergency and palliative care. Dr Andrew White, Consultant in Thoracic Medicine at Gloucestershire Hospitals NHS Foundation Trust
24 Programme Leader: Paul Jennings
Reducing Clinical Variation – We will elevate key issues of clinical variation to the 2.4 Reducing system level and have a new joined up conversation with the public around some of Clinical the harder priority decisions we will need to make. We will continue to build on our Variation variation approach with primary care, deliver a step change in variation in outpatient follow up care and promote a ‘Choosing Wisely for Gloucestershire’ and Medicines Optimisation approach, and undertake a Diagnostics Review. This programme will set the dial for our system to close the Care and Quality Gap.
Clinical variation at system level, to address key priority setting decisions together
1 Develop Medicines Deliver follow up 2 Implement Learning 1
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supported by diagnostics review and next stage of Y delivery for Choosing Wisely of county in Choosing Wisely years 3-5 conversation with particular support of programme the public urgent care strategy Choosing Wisely, Medicines Optimisation and Diagnostics Review Diagnostics and Optimisation Medicines Wisely, Choosing
Clinical variation is an issue that spans all aspects of care. In year one, we will continue to work on variation in primary care, learning from delivery to date, and will focus as a system on a shared Medicines Optimisation programme, reducing variation in outpatient follow up care and commissioning a review of our diagnostics utilisation to inform a programme of work to start in 2017/18. Our Outpatient Follow Up Project is already underway and set to deliver significant movement back towards upper quartile benchmark position in 2017.
In 2016/17 we will commission a review to understand the use of diagnostics across our system. We believe there is currently significant variation in the use of diagnostics and that a more innovative approach to diagnostics provision can provide essential support to our urgent care service redesign.
In terms of Medicines Optimisation we know that medicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. In an era of significant economic, demographic and technological challenge it is crucial that patients get the best quality outcomes from medicines. However, there is a growing body of evidence that shows there is an urgent need to get the fundamentals of medicines use right and that medicines use today is too often sub-optimal. Medicines Optimisation represents a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient centred professionalism, and partnership between clinical professionals and patients. Medicines Optimisation is about ensuring that the right patients get the right choice of medicine, at the right time. By focusing on patients and their experiences, the goal is to help patients to: improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety.13
3 Royal Pharmaceutical Society, Medicines Optimisation: Helping Patients make the most of their Medicines
25 We will take a joined up approach in our county to Medicines Optimisation and will support it with a programme embracing the principles described in the Choosing Wisely approach. Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary. We will have a new conversation with the public to help patients engage their clinicians in these conversations and empower them to ask questions about what tests and procedures are right for them.
We will also work with our population to minimise waste of medicines and other medical supplies, and prioritise treatments that provide the most potential benefit per pound. We know that this will mean we need to make some difficult choices. One of our first changes has been to re-appraise the approach that we are taking to prescriptions for food items, and we intend to set a new approach for the commissioning of Gluten Free food and sip feeds this autumn. We will also need to look carefully at a number of other areas that are being considered across the NHS in England, including prescriptions for basic over the counter medicines and approach to issuing repeat prescriptions, where we could prioritise this funding to other treatments where there is a higher level of need.
One of our first year priorities will be to develop a new and innovative medicines optimisation approach for patients living with pain, considering the role of pharmaceutical interventions, the pathway of care and new ways to provide alternative and holistic support to this often complex group of people. This approach will be informed by a pilot we have delivered as part of our Cultural Commissioning Programme in 2015/16 for men living with chronic pain.
Our system is currently in the process of strengthening the number of Clinical Pharmacists working with our local GP practices. The CCG successfully applied to NHSE three year Clinical Pharmacist Pilot and has Clinical Pharmacists working in five practices. A number of other GP practices have employed Clinical Pharmacists to widen the degree of skill mix within their general practice we are supporting the continued development of Clinical Pharmacists by supporting structured independent prescribing training to appropriate Pharmacists.
By 2017 we will have: •• Evaluated the learning from our approach to managing variation in primary care Maximising the effectiveness and getting “ best value for each ‘Gloucestershire Pound’ •• Designed and started to implement a joint Medicines is essential for all our services which spend public Optimisation Programme money. Making our money go as far as possible is •• Started our new conversation about Choosing Wisely something we all take for granted in our everyday with the public in Gloucestershire lives. This ‘Choosing Wisely’ approach must of course be fair, transparent and have a wide level •• Commissioned an independent review of diagnostics of agreement that this is the right thing to do. We provision must all try to ‘Choose Wisely’ in our personal decision making and in shared informed decisions •• Developed and delivered an innovative pain pathway with health and care providers and in a spirit of across our system common purpose and shared values make sure By 2021 we will have: that we are all contributing to squeezing the best value out of our inevitably limited resources. This •• Developed a new culture and approach to will not always be easy to accept and not always Medicines Optimisation in Gloucestershire, delivering getting all we want, in significantly improved patient outcomes and order that others with more ensuring an efficient use of resources (measured by opportunity to benefit can benchmarked position as per right care) have, will be inevitable and sometimes hard to take but •• Implemented a new diagnostics model for if we can achieve the right Gloucestershire based on the findings from our trust, transparency and fair review processes we can stretch •• Implemented a step change in rates of follow up care every pound much further and together achieve the •• Considered a review of other areas of clinical best affordable results and variation, such as Pathology outcomes for all the people of Gloucestershire’.
Dr Charles Buckley, Frampton Surgery
26 Chapter 3: Our System Development Programme
As a group of health and social care partners we have worked together to develop a shared System Development Programme to ensure our system is in good shape to deliver against the challenging agenda set out in this plan.
3.1 Organisational Development Programme Leader: Shaun Clee
In order to successfully deliver our Sustainability and Transformation Plan we need to develop the right culture within and across our organisations and invest in skills and leadership to support people to work in new ways across the system. We want people who work for us to adopt the values and behaviours agreed by the system and we are committed to developing our senior leaders to model and cascade these and are working together as a community to take this forward. We have established an Organisational Development (OD) and Workforce Strategy Group as part of our STP governance which is made up of representatives of our STP partners. This group has developed a work programme with a focus on Culture, Capability and Capacity. This work programme is an System Development Programme Development System annex to this STP. Please see Annex C.
By 2017 we will have:
•• Confirmed the values we want to work to as a system and align our organisational strategies to the vision and these values •• Agreed a model for distributed leadership which supports people to lead our 12 STP priorities across the system •• Developed a leadership network across our footprint and train 100 leaders in the values to be role models within their organisations •• Trained 300 staff in service improvement and change management skills
By 2021 we will have: •• Introduced 500 shared and rotating clinical roles to support our new models of care •• Agreed and embedded the One Gloucestershire culture as evidenced in staff survey results •• Made key decisions about the shape our system needs to take to support our new models of care and made the transition from organisation to system development
3.2 Quality Academy Programme Leaders: Deborah Lee, Shaun Clee We are working to develop a system wide approach to quality and service improvement through the development of a countywide quality academy. Gloucestershire STP partners already have a good foundation of capability and capacity for service redesign, quality improvement and innovation to build upon. We are engaging with the West of England Academic Health Science Network and the national NHS Quality Service Improvement & Redesign (QSIR) College to ensure application of the latest thinking, application in practices and education materials. We plan to commence system wide learning programmes from Autumn 2016. We plan that participants of our Quality Academy will be able to access a range of support including coaching, access to on-line resources (e.g. local case studies) and action learning sets. We believe that investment in creating a system wide approach will support us to deliver our transformational goals. We will develop and include a new approach to building improvement capability in primary care to ensure we support primary care to make the transition needed to work as a central part of our New Models of Care.
By 2017 we will have: •• Developed and launched a collaborative system wide academy with a curriculum designed to meet the needs of system-wide transformation and quality improvement •• Scheduled programmes to meet the needs of teams responsible for the delivery of STP strategic priorities •• Trained approximately 200 key service improvers, with a further 200 trained each year •• Built on our case reviews to inform improvements in pathways and discharge
27 By 2021 we will have: •• Embedded our approach systematically across the Gloucestershire System to enable exceptional joined up working across partner organisations and effective delivery of transformation goals
3.3 STP Programme Development and Governance Models Programme Leaders: Mary Hutton, Paul Jennings Whilst our STP in Gloucestershire has evolved from our work together as a system, we have laid out a significant challenge in this STP. The priorities have been developed through sustained work with system partners, clinicians and through stakeholder engagement events to inform our plan development and we have a programme of work to support the development of the STP programme architecture. This includes the development of a shared Communications and Engagement plan, Finance and Resources Plan and Performance reporting across all of our delivery programmes.
To support plan delivery, we are developing a Memorandum of Understanding (MOU) to cover the STP, with detailed schedules to support the four main programmes of Enabling Active Communities, Clinical Programme Approach, Reducing Clinical Variation and One Place, One Budget, One System. The MOU will incorporate the Kings Fund 10 overarching principles for integration. It will set out the way we have agreed to work together across our system, confirming our approach to sharing of risk, information sharing and governance and clinical governance in support of integrated working.
By 2017 we will have: •• A system wide Sustainability and Transformation Plan developed with delivery co-ordinated through agreed governance structures •• Agreed a Memorandum of Understanding (MOU) that supports the new STP collaboration approach and through this ensure a joined up approach to managing resources, risks and engagement across our STP priorities
By 2021 we will have: •• A ‘One Gloucestershire’ approval through our commitment to reducing the 3 gaps collectively and delivery of this plan •• Supported our system to work together to ensure success of our programmes
28 Chapter 4: Our System Enablers:
4.1 Joint IT Strategy Programme Leader: Shaun Clee
We have a shared approach to developing a Digital Road Map and have developed a Local Digital Roadmap Footprint (Gloucestershire) aligned to our STP boundary. We will digitally enable people to support their care, support staff in the adoption of new technologies, utilise data to support commissioning and work towards becoming a paper free NHS by 2020. As a system we have a shared records implementation plan: Joining up Your Information (JUYI). This will enable those involved in the delivery of urgent care services to be able to see all records held about a patient in the County in 2017/18. The ability to share information across professionals and organisations is fundamental to supporting the effective delivery of our new models of care. It will improve the quality of clinical decision making and support the development of electronic care plans. We are committed to using technology to support more efficient working e.g. through roll out of Electronic Prescribing and E-rostering. We also see the use of technology as pivotal to supporting our self-care agenda and we are working with the ASHN test bed to evaluate the use of apps in our clinical pathways. We have established a Joint IT Strategy Group to take this work forward and the LDR roadmap/strategy is available on request as Annex F.
By 2017 we will have: •• Introduced a public facing directory of services to support people to understand local pathways and Over the last decade support opportunities in their communities “new Technologies have changed the care we can •• Delivered Joining Up Your Information (JUYI) offer. Now it is time to bring the Information about you •• Created a pool of decision support tools for use at together from our separate the point of delivery/care
System Enablers: IT, Primary Enablers:System Care, IT, Estates and Workforce systems to provide the right By 2021 we will have: care at the right time. •• Become a paper free NHS Dr Paul Atkinson, Chief Clinical Information •• Enabled clinicians across the county to see relevant Officer, CCG information about patients at any point of contact
4.2 Primary Care Strategy Programme Leader: Dr Andy Seymour
Developing a resilient primary care sector that supports our goal of delivering joined up care closer to home will be key to our success in Gloucestershire. Our Primary Care Strategy (available on request as Annex H) sets out how we will support the primary care workforce and infrastructure, offer patients increased access, and how primary care will develop to work more collaboratively at scale. Primary care is a central component in our plans for joined up care and care co-ordination as set out in section 2.2 of this plan.
By 2017 we will have: •• Offered 5,000 additional appointments per month across primary care through our Choice Plus scheme and our new integrated urgent care model •• Ensured 10% of patients are actively accessing primary care services online or through apps •• Invested £1.2 million in General Practice sustainability and transformation plans •• Practices starting to collaborate to deliver primary care at scale
By 2021 we will have: •• Delivered 35 additional pharmacists qualified as prescribers working in practices, 65 additional GPs and 45 whole time equivalent advanced/specialist nurses, supported by our retention and return to practice programme •• Ensured a minimum of 95% patients are able to access digital primary care services, online or through apps 29 •• Ensured 100% population has access to weekend/evening routine GP appointments •• Achieved Good or Outstanding ratings from CQC for all 81 of our practices •• Delivered, as a minimum, the eleven key strategic primary care practice developments as prioritised by our six facet survey •• Practices collaborating in 30,000+ patient population units, delivering place-based, integrated, provision for the population they serve
We are serious about change, not for the sake of “change, but in order to deliver a sustainable, high quality primary care service in to the future. It’s what we as clinicians want to see and what our patients need. Whether it’s tackling the workforce challenge, reducing bureaucracy or supporting new ways of working in, and across practices, we are determined to do what we can locally.
Dr Andy Seymour, Heathville Medical Practice
4.3 Joint Estates Strategy Programme Leader: Peter Bungard
Partners within Gloucestershire, including the County and District Councils, Police, Fire Service, Ambulance Service, Gloucestershire NHS Foundation Trust, Gloucestershire Care Services and the 2Gether Trust have set up a ‘One Gloucestershire Estates’ initiative. This group has mapped information on all assets held by all organisations as well as collecting and sharing capacity and usage data. Many opportunities have already been taken to rationalise land and buildings as well as implementing some colocation models/public sector hubs. It continues to identify further opportunities to better utilise public sector assets across the wider estate within the county. More specifically, the CCG has approved a Primary Care Infrastructure Plan (Available on request as Annex G) for the period 2016/ 2021 setting out key priorities for investment in GP surgeries to deliver new models of care. The STP now provides the catalyst, in conjunction with the wider strategic plan, for taking this strategy forward to meet the following ambitions: •• Enhance the patients’ experience; •• Provide staff excellent facilities to work in; •• Use the existing estate more effectively; •• Reduce running and holding costs; •• Reconfigure the estate to better meet population needs; •• Share property (particularly with social care and the wider public sector); •• Dispose of surplus estate to generate capital receipts for reinvestment; •• Ensure effective future investment.
By 2017 we will have: •• Identified and implemented quick wins within the existing estate •• A strategy in place for optimum configuration of wider Gloucestershire estate •• New development with identified benefits and return on investment providing value for money •• Clear service delivery strategies linked to estate provision
By 2021 we will have: •• Implemented joint strategic estates strategy •• Disposed of all surplus assets •• Place based service delivery achieved with strategic partners •• Clear flexible working arrangements in place supported by optimised space and IT provision
30 4.4 Joint Workforce Strategy Programme Leader: Shaun Clee
As part of our Joint OD and Workforce Programme we are working with partners across our footprint to understand our current workforce, address key gaps and support the development of the workforce we need to deliver 7 day working commitments and our new models of care. Our 3 priorities are:
•• Developing a sustainable primary care workforce •• Developing a sustainable nursing and Allied Health Professions (AHP) workforce •• Ensuring that our workforce has the skills to work effectively within new models of care and to work collaboratively to meet the three Five Year Forward View gaps We are actively supporting the development of new roles to help us to bridge our workforce gaps, to widen access to the healthcare professions and respond to national directions. Our expectation is that whilst workforce numbers will broadly stay level, the skill mix within our staff profile will change to match new healthcare models and current availability gaps in key professions. We are pursuing innovative developments including proposals to explore the concept of having a University Technical College, wider provision for registered nurse education in the county and working with our Local Economic Partnership to develop a collective approach with local schools and colleges. We are committed to developing a single Gloucestershire branding for health and care recruitment so that we can attract people to live and work within our diverse county. We are working to understand opportunities for greater productivity and efficiency within our workforce by reducing agency spend and introducing supportive technology. Our key challenge is to further develop our future workforce projections and to anticipate the roles and skill mix we need in the future and to support our financial gap. We are working closely with the new care models programme and the pilots within our STP to understand how we need to adapt our current projections to meet these needs. The OD and Workforce action plan is included at Annex C.
By 2017 we will have: •• Developed a single Gloucestershire branding to support our health and care recruitment in the county •• Refined and developed our workforce projections for 2020 •• Supported the development of nurse associates as part of the Rapid Follower Wave •• Supported 400 staff with CPD masterclasses that support our STP goals
By 2021: •• Introduced a range of new and different approaches to education and learning that is unique to Gloucestershire and supports the increased number of healthcare staff becoming registered progression i.e. nursing. •• Trained 2,000 staff in health coaching, supportive technology and healthy lifestyles •• Delivered the 7 day working standards •• Achieved further integration of ‘back office’ functions across our system •• Achieved a reduction in agency and temporary staff costs and a joined up approach to workforce capacity management across all partners.
31 Chapter 5: Impact of Change
5.1 Financial impact
In 2016/17 the Gloucestershire STP footprint has faced some financial challenges, with an emergent deficit at Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) impacting on the starting position for our STP plan. . The scale of the challenge for our system is significant as outlined in the previous section. System benchmarking has indicated the headline savings opportunities for each of our programmes; these are set out below for information: Gloucestershire STP Mitigations to address 2020/21 financial gap
CommunitySchemes WideEnabling Communities ActiveClinical Approach ProgrammeReducingVariation ClinicalOne OnePlace, system One OtherBudget, LocalCommissioning AuthoritySpecialised Commissioning Provider CIP STP Funding 250
200 n o
i 6m 9m a t g i 150 16m 1m 1m t i m
£ m 36m t 20m a s
c 100 e r o F
50 70m
40m
226m
Gloucestershire STP: Opportunities to address 2020/21 residual gap: The system is committed to owning and working together to deliver these savings. There will inevitably be additional costs inherent in delivering change, not just in terms of costs to support new ways of working as they develop but also in terms of the capacity needed to design and deliver at scale and pace.
Allocative Allocative efficiency: is about whether to do something, or how much of it to do, rather than how to do it. Allocative efficiency in health care is achieved when it is not possible to increase the overall benefits produced by the health system by reallocating resources between programmes of care Technical Technical efficiency: is about maximising the output that the system gets from given quantities of inputs and is linked to the concept of cost effectiveness. The combination of technically efficient inputs that minimises the cost of achieving a given level of service is that which is cost effective Structural Structural efficiency: is a component of technical efficiency and is concerned with ensuring the most efficient use of our fixed assets and overheads
32 Further Detail of Programme Level Savings: Type of £m in Area Summary of Opportunity Scheme bridge Allocative Enabling Active Opportunities to reduce overall demand through investing in a range of Communities interventions identified as best practice in health prevention and self-care. These areas should lead to a lower incidence of long term conditions. 20 Demand reduction is lower in the first five years and increases over the longer term. The opportunities have been developed using evidence from a number of sources including NICE and Public Health England. Allocative Clinical Analysis of Benchmarking data for Gloucestershire system shows Programme opportunities of £30m if we get to Upper Quartile performance and 20 Approach (CPA) a further £10m if we can get to ‘Upper Decile’ efficiency compared to similar counties. Technical Reducing Medicines Optimisation and management benchmarking has shown that Clinical moving to Peer Upper Quartile performance will save the system £20m. Variation Opportunities have also been identified in diagnostics, pathology, 21.7 variation in care setting and in primary care practice, these are estimated to be able to deliver c£8m. Structural One Place, One Analysis of the urgent care standardised admissions ratio shows that Budget, One getting to Upper Quartile performance compared to peer group would System save £10m. (n.b. some of these opportunities may need to be delivered 9.5 through the Reducing Clinical Variation or Clinical Programme Approach strands once further analysis identifies the changes required). Structural Joint IM&T Service changes associated with a number of IM&T developments Strategy including enabling care professionals to see a patient’s record, thus 5 reducing duplication, saving time, use of apps by patients and care professionals, digital appointments etc. Structural Primary Care Reduction in secondary care demand through better ways of working Strategy within primary care itself enabled by changes to premises and supporting 1 infrastructure. Structural Estates Strategy Countywide estates usage is being reviewed to look at consolidating into fewer locations, centralising any non-frontline services and reviewing 3 numbers of locations that services are provided from. Technical Joint Workforce Opportunity for a reduction in agency and temporary staff costs, different Strategy ways of working, development of different types of role. Facilitated by a 5 joint leadership and cultural change programme and a joint approach to recruitment and induction. Technical Other Review of corporate and other functions across the county, opportunity and for more integration of “back office” functions across the system. 6 Structural Allocative Local Authority GCC – Social Care Plan – the Local Authority is operating and further Schemes developing plans for preventative interventions and system changes that 36 should reduce demand for adult social care. It also has plans in place to manage the public health spend in line with funding. Allocative Specialist Range of schemes identified by specialist commissioning (to be assigned 20 Commissioning to key programmes once further detail known).
33 Technical Other The Carter Review has identified £21.2m of opportunity across the next 5 years for Gloucestershire Hospital NHS Foundation Trust which is built into the Trust’s cost improvement plans (CIP). Opportunities will be explored by the other provider Trusts to see what can be carried across to their individual Cost Improvement Programmes (CIP). Opportunities have also been identified through the reconfiguration of services within the acute hospital, however, delivery of these is dependent 52 on capital availability to enable these changes. The Community and Mental Health Providers are both active in reference cost and other bench marking analysis with both of them benchmarking favourably in the 2014/15 comparisons. Nonetheless, they are both targeting areas where they are high in benchmarking and also identifying opportunities where there is variation in cost / contact in different localities within the Trust to ensure the provision of cost effective services.
Proposed Investments in Transformational Change: Our current assumptions set out in the financial templates supplied to NHS England currently assume that headroom is delivered at footprint level each year. If agreement is reached to deploy commissioner headroom as set out below, then as a system, we will be able to invest this non-recurrently in our transformational programmes; which will offer the opportunity to move faster towards delivering system sustainability.
Source Of Funds Detail %age Headroom 2017/18 50% will be planned to be spent non recurrently funding to pump prime 1% CCG and 2018/19 transformation. allocation
50% will be uncommitted at the start of the financial year and will be utilised according to national business rules.
Capital
Source Of Funds Detail £m National capital GHNHSFT – Estimated capital investment in new models of care for Gloucestershire Hospitals Trust (will be revised following outputs of public c. £70m engagement and subsequent consultation) National capital, Primary care estate – In line with primary care estates strategy, development ETTF bids, 3rd party of a fit for purpose primary care estate to enable delivery primary care of £33m developer capital primary care in accordance with the primary care forward view National capital, Local Digital Roadmap – Funding to resource investment required to deliver £13.3m ETTF bids the IM&T capabilities required within Gloucestershire to support the STP National capital, Development of Community Infrastructure – estimate will be revised following c.£14.5m other Trust capital output of public engagement and consultation
We will create a cross organisational project team to support delivery of our financial savings programme across the lifespan of the STP.
34 aintain ‘top performing status’ for how well supported people with a long- with people supported well how for status’ performing ‘top aintain health the by measured as carers of life of quality performing’ ‘top aintain quit still have who smokers of number for status performing’ ‘top aintain at smoking women pregnant of number for status performing’ ‘top aintain chievement of the 4 hours A & E waiting time target time A & E waiting 4 hours the of chievement targets time waiting ambulance minute 19 8 and of chievement A A M M M M term condition report feeling to self- manage their conditions their manage self- to report feeling condition term status score (EQ5D) after 4 weeks delivery of time • • • • • • Care and Quality Gap Indicators to programmes linked • • • • • • ove from ‘below average’ to ‘top decile’ for asthma for decile’ ‘top to average’ ‘below from ove emergency for decile’ ‘top to average’ ‘above from ove ove to ‘top decile’ for percentage of over 16 year olds year 16 over of percentage for decile’ ‘top to ove asthma, for rates detection average’ ‘about from ove ncreasing participation by men in weight management weight in men by participation ncreasing Standardised Admission Ratio at or below 90 hospitalisation for chronic ambulatory care sensitive conditions M emergency admission rates M normally not would that conditions acute for admissions require hospitalisation M M inactive physically as classified M decile’ ‘top to CHD and hypertension I women to equivalent are they so that programmes • • • unplanned for decile’ ‘top to average’ ‘above from ove • • • • • • Health and Wellbeing Gap Indicators linked to programmes to Gap IndicatorsHealth Wellbeing and linked • • • • • Programmes Programmes Enabling Active Communities - CareSelf and Plan Prevention One One Place, Budget, One System 5.2 Delivery Impact This STP. our of delivering impact the to demonstrate identified initiatives and programme by metrics outcome level high of overview an provides below The table specific the within available These are monitoring. and developing for accountable is it measures of set a further have will programme each and exhaustive not is list gaps’ ‘3 our in indicated as improve to wish we areas the to back relating metrics care and health of a range on impact demonstrate will which plans programme as table this in included not are enablers Our 5.1. in section referenced is Gap Efficiency and Finance the on programme each of impact the of assessment Our analysis. annexes. attached the in available is programmes enabling regarding plans detailed more 35 Adherence to NICE ‘Do Not Do’ recommendations Do’ ‘Do Not NICE to Adherence Gloucestershire in Variation of Practice review local of findings Implement Choosing Colleges Royal Medical of Academy of recommendations Impement Wisely report NHS Constitution compliant delivery across all pathways all across delivery compliant NHS Constitution targets access Therapies Psychological to Access Improving of Achievement targets diagnosis dementia of Achievement patients asthma of proportion for quartile’ ‘top to average’ ‘below from Move with annual reviews Measures Outcome Reported Patient for performance quartile top to Move replacement knee and hip for (PROM) for quartile top to performance average’ ‘above upon improve and Maintain a structured attend who a year less than diagnosed diabetes with people education course to 2020 2 by 1 or Stage at diagnosed cancers of proportion the increase To 62% • • • • • • • • • • • • • • • • • • • • Medicines Optimisation Dashboard (NHS England) Continue to add new pathways to G-Care website and and G-Care website to pathways new add to Continue pathways on instance first the in focusing usage monitor urology, neurology, gynaecology, gastroenterology, for dermatology. ENT and Maintain ‘top performing’ status for number of deaths in in deaths of number for status performing’ ‘top Maintain better) (less is hospital in prevalence diabetes for performance decile top Achieve over 17s a to access to patients stroke for SSNAP targets Achieve thrombolysis and 4 hours in unit stroke mortality premature for performance decile top Achieve conditions respiratory from performance quartile’ ‘top to average’ ‘above from Move NICE all achieved have that patients diabetes for targets treatment recommended by 75% achieve to survival one-year improve Significantly cancers all for combined 2020 Top decile performance of GCCG against metrics on the the on metrics against GCCG of performance decile Top • • • • • • • • • • • • • • • • Clinical Programme Approach Reducing Clinical Reducing Clinical Variation 36 Chapter 6: Implementation 6.1 Communication and Engagement Strategy and Plan
In developing our two phase communications and engagement approach we have drawn upon published national guidance24, as well as our local experience of what works well in Gloucestershire.
Phase One will support countywide engagement regarding our plans for new ways of working and new models of care. This will build upon our earlier Joining Up Your Care engagement35, when over 2000 local people were involved in shaping our current thinking. Phase One will run through autumn 2016 to early spring 2017.
Phase Two, will support our legal duty46 to consult with the public regarding more detailed proposals for service change. Phase Two will commence during summer 2017.
For Phase One, we have identified key stakeholders and plan to target our communications and engagement activities in ways to maximise their interest and involvement. We have prepared key messages that are easy to understand for both individuals, staff and partners who are frequently engaged with health and care services, as well as for the wider general population, for whom health and care is not something they think about very often. Our engagement approach in Phase One will include both qualitative and quantitative methods such as facilitated deliberative events, public drop-ins and staff feedback events, Information Bus visits, and online surveys.
Our aim is to ensure we achieve comprehensive engagement, co-production, consultation and communication with local people throughout the life time of the STP. We want everyone who has a view to be able to have their say and know that their voice will be heard and feel confident that the impact of their contribution will be recognised and acknowledged.
Our Sustainability and Transformation Plan (STP) Communication and Engagement Strategy and Plan states that during Phase 1 ‘Engagement’ we will:
zz Establish a calendar of existing events zz Establish a calendar of additional events/engagement sessions On publication of the STP in November we will contact 1200+ contacts on our Stakeholder database. This communication will include details of the STP document and STP Short Guide (including questionnaire). The communication will invite stakeholders to let us know if they would like us to meet them to discuss our STP. zz Capture public interest We will use the STP engagement period to obtain expressions of interest to be involved.
4 https://www.england.nhs.uk/wp-content/uploads/2016/09/engag-local-people-stps.pdf 5 http://www.gloucestershireccg.nhs.uk/wp-content/uploads/2012/03/JUYC-Outcome-of-Engagement-Report-Final-v2.pdf 6 http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted 37 Calendar of Events (planned to date) [Further events, including Foundation Trust Member events and Patient Participation Group (PPG) Network are planned for January – February 2017.]
Date (2016) Event Activity STP Presentation and testing of STP Short Guide and 27 October Healthwatch Board Meeting questionnaire. Your Care, your Opinion – Community Partner Event, STP overview presentation, 3 November Gloucestershire Care Services workshops focussing on STP One Place, One Budget, NHS Trust One System November / December / January / February (venues Information Bus STP Drop Ins /Awareness Raising to be confirmed – across all Localities) Health & Care Overview and 15 November STP Presentation Scrutiny (HCOSC) 15 November (Cancer) STP Clinical programme approach – clinical and lay Clinical Programme Groups 17 November (Respiratory) engagement, awareness raising, discussion 24 November Voluntary Sector Locality Event Community Partner Event, STP overview presentation B&ME Community Health 30 November Community Partner Event, STP overview presentation Event, Friendship Café STP Clinical programme approach – clinical and lay 1 December (Diabetes) Clinical Programme Groups engagement, awareness raising, discussion Health and Wellbeing – 6 December Voluntary and Community Community Partner Event, STP overview presentation Sector Provider Forum STP Clinical programme approach – clinical and lay 6 December (Eye Health) Clinical Programme Groups engagement, awareness raising, discussion 13 December STP Clinical programme approach – clinical and lay Clinical Programme Groups (Muskulo-Skeletal) engagement, awareness raising, discussion Community Hospitals League of 14 December Community Partner Event, STP overview presentation Friends meeting Community Partner event, STP overview presentation, 14 December Stakeholder event workshops focussing on Urgent Care STP One Place, One Budget, One System – focus on Health & Care Overview and 15 December Urgent Care. Engagement begins on Urgent Care model Scrutiny (HCOSC) of care Focus groups for: –Place-Based Care Community Partner Event, STP overview presentation, December / January –Rehab model focus group –Urgent Care Model of Care June (2017) HCOSC Consultation on Urgent Care system model
Survey We want everyone to be able to have their say and know that their voice will be heard. As well as public Drop Ins a survey, print and online, has been created to collect feedback on our STP: www.gloucestershireSTP.net
38 6.2 Delivery Plan & High Level Timeline £m £5m £11m £20m £20m 20/21 £9.5m £21.7m further priorities ning from years 1 and 2 to set set 2 to 1 and years from ning based on progress and Right Care Right and progress on based Lear Identify further priorities programme 17/18 and beyond and 17/18 Pathway to get there get to Pathway pooled on place basis place on pooled of resources and contracting and resources of with Social Movement Working Together at Scale – GP Forward View Forward – GP Scale at Together Working Diabetes Clinical Programmes Implementation of Diagnostics Review Outcomes Review Diagnostics of Implementation Development of Primary Workforce of Development Care New Care Model: urgent and responsive care resources resources care responsive and urgent Model: Care New Support Prevention and Self Care Plan Plan Care Self and Prevention Support Implement system wide allocation approach governance, to Deliver new pathways for Circulatory and and Circulatory for pathways new Deliver Implement Urgent and Community Care Model at wider scale wider at Model Care Community and Urgent Implement Radically upgrade Prevention and Self Care Self and Prevention upgrade Radically Implementation of Primary Care Strategy Care Primary of Implementation 16/17 MSK CPGs programme Implementation of System Organisational Development and Workforce Plan Workforce and Development Organisational System of Implementation Outcomes/Deliverables Joining Information Up Your Countywide Diagnostics Review Deliver new pathway for Dementia for Deliver new pathway Ensuring implementaion of Patient Safety Recommendations – Francis, Keogh, Berwick, Winterbourne Berwick, Keogh, – Francis, Recommendations Safety Patient of implementaion Ensuring Deliver Integrated Respiratory Pathway Continued Embedding ofContinued Social Prescribing Pool Urgent Care resources in shadow form shadow in resources Care Urgent Pool Place based: Integrated model at 30,000 level 30,000 at model Integrated based: Place Initiate delivery of Prevention and Self Care Plan Care Self and Prevention of delivery Initiate Delivery of Medicines Optimisation: Choosing Wisely Wisely Choosing Optimisation: Medicines of Delivery Complete implementation of Cancer, Eye Health and and Health Eye Cancer, of implementation Complete Deliver pilots to reset the dial for Urgent Care System Care Urgent for dial the reset to pilots Deliver Active Clinical Clinical System Enablers Enabling Variation Reducing Approach One Place, Programme Programme Programme One System One Budget, Communities Development Development
39 6.3 Delivery Risks
L x C Risk Risk to System (inc. Comments/Mitigating actions RAG) Capacity and There are considerable resource requirements Complete review of capacity Capability to associated with delivering such large aligned to key programmes and Deliver Transformational change. Organisational capacity ensure this is reviewed at delivery across the county will have a key impact on the board, discussion on commitment 3x3 likelihood of success. Clinical leadership and of resources with CEOs change capabilities will determine likelihood of improvements being sustainable in the long term. Reaching a It has been identified that language, in Common vision established in common goal particular definitions, can be inconsistent core STP plan and supported across organisations. This may affect the by programme level plans. All 3x3 changes of successful collaboration. A common programme documents shared understanding and shared vision is needed going through briefings and sharepoint forward. Changes Whilst it is unlikely national priorities will move Programme office to keep in national away from the principles outlined in the FYFV, watching brief on national policy 3x3 priorities organisations may have to be flexible in their and advise Delivery Board if application should the local environment change. change is required Lack of Closing the gaps may require redesign of Programme Development group external services. Patients and public will be encouraged to manage duties under health stakeholder to participate in all stages of the design to ensure 3x3 and social care act to ensure support for wide and meaningful engagement in line with smooth passage change health and social care act responsibilities. Managing Identified quick wins and pilot schemes will need Short term operational delivery short term to be adopted in the first instance with a clear must remain a key focus of our delivery to longer term road map in place to deliver wider 3x3 system whilst looking to longer ensure longer scale changes. term development term success Workforce The system has identified some key workforce Ensure a system-wide capacity gaps that will impact on workforce supply in key understanding of workforce issues roles across our system. Through the STP we will to agree shared priorities for have a new opportunity to pool our knowledge 3x4 action. Workforce plan attached and take a one system approach to developing sets out more detailed actions to new roles to fill gaps in essential services. work together to develop new roles
40 41 Supporting Documents and Useful Links
The following appendices to the plan are attached or available separately:
Annex No: Description: A Governance Arrangements B Engagement Process C Enablers (Local digital roadmap, Estates, Workforce) D NHS England Ten Big Questions E Plan on a Page summary for each of our programme areas
The following appendices to the plan are available separately:
Annex No: Description: F Local Digital Roadmap G Estates plan – Primay care estates plan only as wider plan is still under development H Primary Care Strategy I Self-Care and Prevention Plan
42 Annex A: Building and Governing the Plan
A.1 Principles of the Plan
Within the Gloucestershire STP all organisations have agreed to work together on the development of more integrated care for service users, which is underpinned by an Memorandum of Understanding to provide clarity regarding the basis on which the organisations will collaborate with each other.
The principles of collaboration are laid out as:
•• Collaborate and co-operate. Organisations will establish and adhere to the governance structure, ensuring that activities are delivered and actions taken as required; •• Be accountable. Organisations will take on, manage and account to each other for performance of their respective roles and responsibilities within the STP; •• Be open. Organisations will communicate openly about major concerns, issues or opportunities relating to the Gloucestershire STP; •• Adhere to statutory requirements and best practice. We will comply with applicable laws and standards including EU procurement rules, competition law, data protection and freedom of information legislation •• Act in a timely manner, recognising the time-critical nature of the Gloucestershire STP and respond accordingly; •• Engage with stakeholders effectively; •• Deploy appropriate resources, ensuring sufficient and appropriately qualified resources are available and authorised to fulfil the responsibilities as agreed; •• Act in good faith to support achievement of the Key Objectives and compliance with these Principles. In addition the MOU details the principles we will work to in addressing the finance and efficiency challenge across the system, as detailed in section 1.5. This framework ensures we have a robust agreement on how Gloucestershire as a system can deliver its STP, within the governance framework detailed overleaf.
43 A.2 Working Together for Gloucestershire
Statutory Accountable Bodies Key: STP Advisory Gloucestershire Health and New Groups Group Strategic Forum Leadership Wellbeing for STP Glos STP Delivery Board Board Existing Groups System Development Programme
Countywide OD STP Programme Governance Quality Academy Strategy Group Development Models
Health and Wellbeing Gap
Care and Quality Gap
Finance and Effi ciency Gap
One Place, One Clinical Enabling Active Reducing Clinical Budget, One Programme Communities Variation System Approach
Working Together to Enable Our System to Deliver (System Enablers) Primary Care Joint Estates Joint Workforce Joint IT Strategy Strategy Strategy Strategy
44 Annex B: Engaging with our Communities
We are fortunate in Gloucestershire to have been working in our STP footprint (area) for some time and the STP builds on the foundations of our system wide ‘Joining up your Care’ programme, which was subject to significant patient and public engagement. We expect to develop detailed proposals based on STP priorities for discussion with the public over the course of the year and we will be working on a public guide to the STP this Summer to start to aid conversations.
We consider it to be of the upmost importance that patients and the public are given opportunities to have their say on any future options or proposals for change. Should a future proposal/s be deemed to constitute significant service variation, then the health and social care community is committed to fulfilling its statutory duties with regard to public consultation.
As our STP describes, the future looks particularly challenging and we will need to be innovative and ambitious in how we develop services and use the resources available to us. Prevention of illness, high quality patient care and safety will remain our priorities throughout.
We have developed a Sustainability and Transformation Plan (STP) Communication and Engagement Strategy and Plan. This Communication and Engagement Strategy and Plan has been produced to support the STP development and implementation process and ensure comprehensive and planned engagement and communication with interested parties throughout the life time of the project.
This is a live document – the action plan will be updated to reflect the project plan and the recommendations of the STP Advisory Group and Delivery Board. The purpose of the Strategy and Plan is to:
•• Ensure the Communication and Engagement work programme is integrated into the Governance and overall STP programme structure (shared milestones/timelines) •• Ensure robust and sustainable communication arrangements are in place so that all identified audiences are kept up to date with progress (development of the plan and implementation) •• Ensure the approach to Communication and Engagement is system wide – emphasising system wide ownership – both constituent organisations and C&E leads •• Ensure that stakeholder groups are communicated with in the right way and in a timely manner e.g. staff and community partners are aware of developments before other external audiences •• Ensure communication and engagement activity, materials and messages are relevant to each target audience •• Ensure that the STP programme engages with all interested stakeholders – including the seldom heard •• Ensure that key stakeholders know how they can have their say and influence the work of the programme •• Demonstrate and inform stakeholders of the impact that their feedback has made.
45 Delivery Date October 2016 January 2017 December 2018 September 2017 October 2016 Outcomes Leaders will feel supported to lead for and across across and for lead to supported feel will Leaders and with collaborate will Organisations system. the roles these assuming are who support leaders feel and self-care to motivated are Patients Improved choices. healthy make to supported experiencepatient and satisfaction. Increased patient activation and patients to interventions brief provide Staff living healthy to lead that individuals help to technology using in confident feel Patients their conditions manage integrate and technology use to equipped feel Staff practice their working into this and economy the within best practice adopt We training outsourcing of cost the reduce People have the skills we need to deliver the goals goals the deliver to need we skills the have People ability their in confident STP feel the and of How? Develop joint commissioning skills & resources building building & resources skills commissioning joint Develop joint where experience and arrangements existing on social and health across exist already roles commissioning care resources redesign transformation/service Joint will network leadership of work previous on Building pool thinking between organisations on leadership leaders’ ‘top with work on drawing including models, out roll then and agree model, Develop programmes. across system e.g. Health co-production of a culture Embedding and behaviours healthy mobilise to coaching through person care led – Making agenda prevention and self-care Supporting across module e-learning common Count, Contact Every lifestylesGloucestershire healthy for support to –use technology of workforce IT enabled (telehealth care and health across monitoring remote homes/ care practices/ domcare/ in training telecare and to devices Assistant Digital Personal nursing). community spent time maximise to workers other and carers enable with patients. social and health the support within training Offering the passport for a training Develop community. care county Ensuring embedded improvement capability e.g. through embedded through capabilityEnsuring improvement e.g. arrangements Development Professional Continuing new classes master – transformation Change Activity Required Shared approach to to approach Shared capabilityimprovement and training delivered system to staffto across support transformational change describe and Develop for model a shared distributed leadership care and health across embed to out roll system, capabilities key Developing shared co- building to approach production capability needs training Define analysis and address gaps new of account taking care of models Provide Mutual Mutual Provide support learning and opportunities using our in opportunities system Workforce Strategy Embed improvement capability Model for distributed leadership Build co- production capability with clinicians and carers Enable the workforce in key skills (IM&T) Work streams Work 1 2 3 4 Annex C: Enablers Annex C.1 Gloucestershire Organisational and Workforce Development Delivery Plan 46 January 2018 June with 2016 6monthly refresh April 2017 Ongoing as and identified March 2017 Staff are able to rotate and take up new roles across across roles new up take and rotate to able are Staff without delay organisations our our of a system-wide understanding have We action for priorities agree we issues, workforce system the best for is what on based and workforce future our for plan a robust have We fashion a timely in workforce the developing are we care of models our of out roll the underpin to work our to approach based evidence an adopt We wheel the re-inventing avoid we and support 7 day to plan resource agreed an have We working DBS clearance to follow individual follow to clearance DBS that practice HR/recruitment of Assess elements other can be shared. – pathways care social and health integrated Develop including leadership pathways a developing workforce, on information Sharing tools, profiling workforce adopting language, common capture, data improving issues, common understanding to this using elsewhere, to compare we how at looking supports system our this how at look actions, our inform review under information keep plans, to need profile workforce does future – What Future and mix skill (review care of models support new be to opportunities) integration roles new for opportunities the are Now – What – roles care social and – health Apprenticeships including capability and capacity the harness further we can how sector to independent and voluntary private, the of we – Can professionals care social and support health economy care and health all across pathways career build workforce groups? bring HESW and networks wider – e.g. in Participate national other and Vanguards from Learn learning back their at development workforce had have that initiatives workforce national into linked are we that Ensure core. Association, Government Local in work development Services, Public Social Adult for Directors of Association Association. Managers Service People future on impact will working 7 day how Identify profiles workforce Learn from best practice best practice from Learn care to access Supporting Creating one system Profiling Workforce strategic 5 year Develop plan workforce Supporting New Models Care of Model Current system workforce profile Develop future workforce profile(skill mix) • 5 6 • 47 April 2017 Ongoing October 2017 December 2016 Ongoing September 2017 January 2017 June 2017 June Pupils and career advisors have a better a better have advisors career and Pupils opportunities career of range the of understanding to encouraged are people Young care. and health in earlier an from careers care and health about think these of uptake in increase see an we and age career pathways. into routes up take to supported are people Young health and care professions its part improving sector in plays The statutory employability a to in Gloucestershire and contributes reduction in people not in employment. in work to come to attracted are People a cohesive are see that can They Gloucestershire. opportunities. of a wealth system offering the recognise Gloucestershire in working People system the by agreed behaviours and values culture, is this and working of ways their as these adopt and staff surveys through evidenced People stay in Gloucestershire and take up training training up take and Gloucestershire in stay People roles new pursue to opportunities Our organisations promote the wellbeing of staff of wellbeing the promote organisations Our We here. work to motivated them keeps which increase productivity staff and reduce absenteeism. Promoting health and care careers as a package to to a package as careers care and health Promoting experience, work Skillsfest, advisors, careers schools, business breakfasts local to linked nursing into pathways local Exploring a University of development and providers education Technical College application on Partnerships Enterprise Local with Work advice LEP and initiative Opportunities Better Building Support driven DWP support to programme employability and advertisements on branding wide community Use primary within work on – build county the promote Social and Health from Learn strategy. workforce care deliver and plan and June end at event recruitment Care and onwards in Septemberadditional event 2016 strategies workforce OD and organisational of Alignment support STPto goals other each from learning of culture and network Support problems common to approaches strategies, of – sharing – so that network a staff of ideas development Explore so we improvements of assessment a rapid have can we can get them quickly implemented understanding people’s improve to mechanisms Develop STP our do partners across different what of Apprenticeships, nurseApprenticeships, practitioner other social role, care roles Education a Community of development the Support Gloucestershire Network for Provider Adopt and sponsor Workplace Wellbeing Charter within within Charter Wellbeing Workplace sponsor and Adopt economy local the STP in partners and Recruitment – Careers – 16+ Pathways Recruitment - Marketing Gloucestershire – Career Retention – those pathways the in working currently NHS Recruitment – Career Recruitment – Career – Schools Pathways Recruitment – Career in not – those Pathways employment embed and Develop and values and vision align organisational strategies where appropriate other each from Learn Retention – Health and and – Health Retention staff of Wellbeing Recruitment - Encouraging JoinPeople to Workforce the Encouraging people stay in to Workforce the Retention - Retention Sustainable workforce Develop and vision, embed values and behaviours to support the STP agenda Actively promote working across boundaries to create enabling culture • • 7 8 9 • • 48 Annex D: Local assessment against NHS England Ten Big Questions
Big Questions Gloucestershire STP Response How are you going to prevent ill health and •• Upgrade self-care and prevention, to fully involve individuals moderate demand for healthcare? Including: in their own health, including delivery of Self-Care and Prevention Plan. •• A reduction in childhood obesity •• Delivery of Enabling Active Communities Programme •• Enrolling people at risk in the Diabetes •• Build on existing collaborations between health and social Prevention Programme care, local government and the third sector to deliver local •• Do more to tackle smoking, alcohol and solutions. physical inactivity •• Continued development and embedding of shared decision making. •• A reduction in avoidable admissions •• Continued provision of Social Prescribing •• Social Inclusion and Social Reablement Programmes •• Mental Health Programme of Interventions •• Adopt a range of innovative technologies i.e. NHSE Digital Test Bed •• Whole system approach to obesity, working with Leeds Beckett University and Public Health England How are you engaging patients, communities •• Development and Implementation of Workplace Wellbeing and NHS staff? Including: Charter •• A step-change in patient activation and •• Continued development of Cultural Commissioning self-care Programme •• Expansion of integrated personal health •• Adopting a range of innovative technologies budgets and choice – particularly in •• Train staff in health coaching, supportive technology and maternity, end-of-life and elective care healthy lifestyles •• Improve the health of NHS employees and reduce sickness rates How will you support, invest in and improve •• Implementation of Primary Care Strategy general practice? Including: •• Investment of £1.2 million in General Practice Sustainability •• Improve the resilience of general and Transformation Plans practice, retaining more GPs and •• Exploration and development of New Models of Care recruiting additional primary care staff to ensure practice collaboration and care co-ordination •• Invest in primary care in line including 30,000 models. with national allocations and the •• Embedding of Choice Plus Service, development of forthcoming GP ‘Roadmap’ package Integrated Urgent Care Model delivering increased •• Support primary care redesign, appointments and improving access for patients. workload management, improved •• Additional Practice support i.e. Prescribing Pharmacists, access, more shared working across Advanced/Specialist Nurses practices
49 How will you implement new care models that •• Implementation of Primary Care Strategy – Primary Care at address local challenges? Including: Scale. •• Integrated 111/out-of-hours services •• Network of Urgent Care Centres across Gloucestershire available everywhere with a single point of •• Evidence based service redesign of Urgent Care Pathways, contact focusing on local out of hospital care. •• A simplified UEC system with fewer, less •• Embedding of centralised, integrated Urgent Care Clinical confusing points of entry Hub, providing a single point of access for health and social care. •• New whole population models of care •• Development of Urgent Care Digital Access Offer. •• Hospitals networks, groups or franchises to share expertise and reduce avoidable •• Development and implementation of system wide plan for 7 variations in cost and quality of care Day Services. •• Testing of New Models of Care – i.e. locality led models for •• health and social care integration with a Frailty, 30,000 population models. reduction in delayed transfers of care •• Responsive community based care enabling our population •• A reduction in emergency admission and to be less dependent on health and social services, by living inpatient bed-day rates in healthy communities, supported by strong networks and timely access. How will you achieve and maintain performance •• Continuation of cross-organisation System Resilience Group against core standards? Including: including delivery of Elective Improvement Plan and Recovery Plan for A&E performance. •• A&E and ambulance waits; referral-to- treatment times •• Continued development of supporting contractual arrangements to ensure robust mechanisms across the system. •• Maintained Referral to Treatment Time with continued focus on management of the market for elective care. •• Activity Plans with key providers to account for activity levels and predicted levels of demand. How will you achieve our 2020 ambitions on •• Development of acute and early diagnosis cancer pathways key clinical priorities? Including: including GP masterclasses. •• Achieve at least 75% one-year survival •• Delivery of Living with and Beyond Cancer Programme rate (all cancers) and diagnose 95% of •• Expansion of Mental Health Crisis Team cancer patients within 4 weeks •• Support for families experiencing Mental Health, drug, •• Implement two new mental heath alcohol and domestic violence issues. waiting time standards and close the health gap between people with mental •• Implementation of Saving Babies Lives Initiative health problems, learning disabilities •• Midwifery Partnership Teams operating in the most deprived and autism and the population as a areas of the county. whole, and deliver your element of the •• Delivery of our Dementia Strategy (2015-2018). national taskforces on mental health, cancer and maternity •• Independent Review of Primary Care Pathway to ensure equitable review, support carers and improve effectiveness. •• Improving maternity services and reducing the rate of stillbirths, neonatal •• Dementia Training and Education Strategy and maternal deaths and brain injuries •• Implementation of BME Community Hub. •• Maintain a minimum of two-thirds diagnosis rate for people with dementia
50 How will you improve quality and safety? •• Development of Quality Academy Including: •• Engagement with South West Academic Health Science •• Full roll-out of the four priority seven Network and QSIR College. day hospital services clinical standards •• Research and Development Consortium for emergency patient admissions •• Supporting development of clinical skills and knowledge •• Achieving a significant reduction in through programme of education and workforce avoidable deaths development. •• Ensuring most providers are rated •• All providers including GPs will ‘Sign Up To Safety’ and work outstanding or good– and none are in collaboratively through local patient safety forum to reduce special measures avoidable deaths. •• Improved antimicrobial prescribing and •• All providers have had a CQC inspection and have resistance rates implemented action plans to address concerns raised and will continue to monitor. •• Antimicrobial Rates are already good in Gloucestershire but we will continue to strive to improve on this position. How will you deploy technology to accelerate •• Delivery of Joining Up Your Information Programme change? Including: •• Digital Transformation GP IT Programme – includes Patient •• Full interoperability by 2020 and paper- Online, Electronic Prescription Service, GP to GP record free at the point of use sharing, Infrastructure Upgrades. •• Every patient has access to digital •• Development of our Local Digital Road Map health records that they can share with •• Digitally enabling patients to support care through use of their families, carers and clinical teams apps, online programmes etc. •• Offering all GP patients e-consultations •• Provider Electronic Patient Record Programmes and other digital services How will you develop the workforce you need •• Implement Workforce and OD Plan developed by Strategy to deliver? Including: Group. •• Plans to reduce agency spend and •• Use coaching to mobilise healthy behaviours develop, retrain and retain a workforce •• Develop model for distributed leadership across our footprint with the right skills and values •• Build co-production capability with clinicians and carers e.g. •• Integrated multidisciplinary teams to through training in health coaching underpin new care models •• Under take modelling of the current workforce profile to •• New roles such as associate nurses, understand capacity and develop a future profile. physician associates, community •• Develop shared values and behaviours and align these across paramedics and pharmacists in general our organisations. practice •• Create an enabling workforce which supports working across organisational boundaries. •• Development of University Technical College and work with Local Economic Partnership. •• Develop single Gloucestershire brand for recruitment. •• Introduce apprenticeships to develop nurse associates. •• Deliver Continuing Professional Development masterclasses. How will you achieve and maintain financial •• A risk share approach aligned to our priorities. balance? Including: •• We will work together to identify opportunities for •• A local financial sustainability plan increased cost effectiveness, minimising the number of steps and driving greater efficiency •• Credible plans for moderating activity growth by c.1% pa •• Improved provider efficiency of at least 2% p.a. including through delivery of Carter Review recommendations
51 Annex E: Plans on a Page
5 - YEAR 3 care i.e. NHSE care - wide to approach - ent and empowered empowered and ent system
Care Plan Care - Complete obesitytackling Full ofimplementation and Prevention Self connected, resili connected, - produce local solutions and services i.e. and solutionslocal produce • • -
management support.management - YEAR 2 wide - facing - led care led care and personalised care planningi.e. Integrated -
care and live in well in live and care Plus Model - based approaches
- OE J B C TE: I V S care - care as part of our care pathways as ofpartour care care -
.” technologies to enable individuals and communities to self to communities and individuals enableto technologies V I: IV S O N communities Develop Social Prescribing Begin implementation of system Begin implementation website website to support self approach to to approach tackling obesity of patient Full implementation of innovative innovative of • • •
P R O G R A M M D M AL R M E OR EE IY : G P V R YEAR 1 Promote healthy lifestyles and self lifestyles healthy Promote health inequalitiesTackling asset through Develop a whole system Develop a to approach obesitywhole and PHE working alongsidesystem University Leeds Beckett thedetect systematically that interventions prevention secondary of key coverage appropriate Ensure early stages of disease i.e. Diabetes Programme Prevention theto commissioning approach of self a strategic Ensure person supports that a system towards Work Commissioning Personal Utilising withinthe our capacity closer andcommunities strengths through working with the Community & Social Sector Enterprise i.e. SocialVoluntary, Prescribing of communities andinvolvement individuals to co Substantial CommissioningCultural Programme services Act in line withCare the of commissioners thecarer across are county range a Ensure Adopt a range Digital Test Bed Digital Test Promote healthy workplace environments i.e. Workplace Wellbeing Charter Wellbeing i.e. Workplace environments workplace healthy Promote • • • • • • • • • • •
a ”. is NHS to
to buildto is and ensuring and y aim communities healthier lives ary procure Social procure Prescribing service health, r health, ies - E A I AE M :
fo responsibility and their Re Implement National Diabetes Programme Developthe and delivery initiate of and Prevention Self Care Plan CPG obesity workshops initiative of workplace healthRollout M capacit e al y volunt to work in partnership work to the need for the r • • • • • fo ies as Communit e sier of person agenc communit y se g it ea Activ programme vision is for Individuals to have the knowledge, skills and confidence to self to confidence and skills knowledge, the have to Individuals for is vision programme P R O G R A M AR M OR G P e g KEY sen mak “Our ew n e Self Care and Prevention Plan led by Prevention Self Public Care and DELIVERABLES DELIVERABLES be “helping people and w improved independenc improved supportin communit the NHS, expressed in the of core function NHS Constitution take responsibilityfor living Enablin with us. We will to deliver approach use this a and Wellbeing Health to close the Health Improving Lives Gap in Gloucestershire. a
52 te te o li e o o li e
anage anage
a e th o gh th o gh a e
eeling to to eeling el
people ith ith a long people
epo t
CARE & QUALITY GAPCARE & QUALITY ondition a e
Maintain ‘top performing status’ for ‘top Maintain for status’ how performing ppo ted ell ‘top Maintain performing’ status for n be o o en p egnant o ing at ti e o deli e ee p o ed health alit p o ed o elated li e o e pe ien e patient p o ed a a o a e e lt theSo ial to e ibing e i e a e ent ad i e and ppo t ondition ondition thei thei nabling patient to el a e a a e ea ed b the health tat o e ‘top Maintain performing’ status for it a te till ho ha e o n be o e Maintain ‘top Maintain performing’ quality • • • • • • •
o
o
p og a e ’
elated alit o elated li e in a oidable andin a oidable li e and li e e pe tan ina ti e ine alit in a oidable in ine alit a oidable from ‘about average’ detection from average’ ‘about HEALTH & & GAP WELLBEING HEALTH ed ed ed ed ed tion ed tion n ea ed n ea ed n ea ed health n ea ed o ithindi id al o long te ondition
di abilit ee li e e pe tan a e a b lato en iti e ondition
n ea ing n ea ing pa ti ipation b en in anage ent eight o e ea old la i iedold a ea o e ph i all o e and h pe ten ion a th a o ate CHD ‘top decileto that the a e to e i alent o en. e e gen ad i ion e e gen percentage ‘top decile’to Move for
• • • • • • • H O W W I L L T H I S C L O S E S . O . C . . T H S W L L O I L W I
and and attendan e o e o e attendan e
app o i atel app o i atel
& & EFFICIENCY GAP
the need o a te a e. the need a e. a te o
in i p o ed o bidit o bidit in i p o ed ill be ill FINANCE a ing a ing e e e e gen ad i ion e e gen e e
o g eate on ill p e ention e lt ed ing e e l ina e o p og a e i that o ob e ti e e pe tation the e appoint ent o tpatient e e e e ea . i e • •
N S N S
53 upon -5 ocial of urgent ocus YEAR 3 ight place, for r anagement and s together the are’ of community with a f n
beds, money and i
-m self work to
in utilisatio n to d neede model of c n erm futur e
supporting services
.” integrated he alth whe ‘new from networks reduction a e model for Integrated e model for are long t to a of earning from Yr1 and 2 to set a new set 2 to and Yr1 from L earning car Community Primary Care. pooled on resources care Urgent countywide support to basis pla ce model. care urgent services
across Gloucestershire • • for the needed by needed
day eading e ar e n revention an d
ommunity c care . he or 7 in
responsive car e responsive
for adoption
and c YEAR 2 care plan f Urgent C ustainable of uality l wellbeing t ensure pe ople be nefi of model of learning our in design system
O B J E C T I V E : S be s use to nd wide
care rimary a on supported w
nd p high q our and ies s
a up best p health/accident a new f care re view ommunity o ill onsult on a new on onsult syste m heal th based and c enable scale access across a
/ make and c
ill o are ill model t
communit
scale c r population i programme rgent 30,000 hat w the engage promoting ide hat w esources to t the mpact upo n by delivering jo ined nd evidence based evidence are ab le h imp lement t hospital time. orward a f that our V I S I O N : I O N I S V o and
igh t ut the f vailable r ear 1 o services a hospitals, approac w model at u Implement Y Design a services deliver an deliver positively i support healthier ensure set
• • o o o o o at the r T local T care suppor t care T T an d Develop effectively T Gloucestershire t
P R OR A G M M D EL E I V E R Y : • • • • • • YEAR 1
or place
f al n shadow i
0,000 every every ased’ thatwill reseturgent and community delivercare to effectiveand efficientservices Programme Programme
and 3 eams T eset the di eset esources m r r
Approach o t ‘place b syste care
t workforce workforce E A I AE M : ake pilots are p C Community rgen
u This programme will focus will focus This programme place based approach to approach place based rgent the best outcomes for for outcomes best the Commissioning based Pool form to t Develo U • • deliver deliver P R OR A G M M Place, One Budget, One System One System One Budget, Place, Place, One aimsBudget, deliver One to System value thebestevery for Gloucestershireapproach taking a wholePound, system KEY “One DELIVERABLES DELIVERABLES The One a is focussed ontaking resources, to pound. Gloucestershire beyond working involve both that areas key two on boundaries , a organisational firstly traditional to secondly and system Care of Urgent our redesign and community New Models for deliver of Care The New Modelscare. will work ofprimary Care and community integrated on focus developing at primary care the 30,000 scale, moving population of working ways new towards GP our practices county. our for clusters 15 GP across
54
A & E urs ho waiting time targetswaiting CARE & QUALITY GAP CARE & QUALITY re integrated approach, leading approach, to re integrated ulatory Emergency Care pathways ough development of integrated ulance ntervention and better health More care provided closer to home to closer provided care More thr services care urgent a through resilience system Improved mo of and support quality care improved for staff access Improved will support earlier i outcomes atients on atients medically list stable ach cluster ervice or those with dementia, complex or those with dementia, Achievement of the 4 4 the of Achievement time target waiting of 8 19 and minute Achievement amb Year on year reduction in numbers of numbers in reduction year on Year p of in utilisation increase on year Year Amb Increased uptake of Rapid Response of Rapid uptake Increased s Named later life professional linked to linked professional life Named later e especially care coordinated Focussed f conditions and frailty psychological
• • • • • • • • • •
emergency admission emergency care nplanned hospitalisation for hospitalisation nplanned u 90 onditions due to focus on to due focus onditions ervices address local health needs healthlocal ervices address HEALTH & WELLBEING GAP HEALTH Improved morbidity for of a for morbidity range Improved c - self supporting Place will based approach ensure s ecile’ ecile’ asthma for admissions for emergency for ecile’ elow for ecile’ chronic ambulatory care sensitive care ambulatory chronic conditions ‘top to ‘below average’ from Move d rates to ‘top average’ ‘above from Move d not would that conditions acute hospitalisation normally require Standardised Admission Ratio Admission or Ratio at Standardised b to ‘top average’ ‘above from Move d • • • • • • H O W T L W H I L C O I S E S L . . and 6,700 fewer A and 6,700 fewer
by 2021 by
& & EFFICIENCY GAP FINANCE ould equate to a £9.5m savings so savings £9.5m a to equate ould esult in more care provided being care in more esult o better manage their care home, at and care theirmanage o better will system Care Urgent A redesigned r people supporting in successful are we If t top compared deliver decile performance expect can we group peer national our to 5,000 fewer approximately be to there admissions emergency & E attendances utilisation will resource be a key this for programme indicator outside of hospital based on the needs of needs the on based hospital of outside of ways new and populations local sectors health different between working Delivering top decile performance Delivering w • • •
DICATORS BENEFITS IN
55
5 -
YEAR 3 continued continued
and and
change in rates of of rates in change - edresearch by and system ort
up care up to top decile decile top to up care up -
Developed a a new Developed culture medicines optimisationto approach of findings implementation Complete Review Diagnostics from Implemented step Implemented follow performance
• • •
YEAR 2 and and
O B J E C T I V E : S
ups Programmes - care - an independent review of diagnostics provision and implement a new diagnostics diagnostics a new implement and provision diagnostics of review independent an V I S I O N : I O N I S V innovation .” G by Developed and Pain deliver an innovative Pathway Programme across Gloucestershire of findings of implementation Begin Review Diagnostic Progress Medicines Optimisation Optimisation Medicines Progress Follow • • •
Commission Commission review our from findings the on based Gloucestershire for model Evaluate the learning from in the from to Primary learning ourandmanaging Care variation approach Evaluate Design and implement a joint across Medicines Optimisation Programme Gloucestershire in public the with Wisely Choosing about a conversation new Have across painour system approach and anDevelop deliver innovative care up of follow in rates change a step Deliver Pathology such as variation, clinical of areas other Review support support P R OR A G M M D EL E I V E R Y : YEAR 1
• • • • • • •
strategy
continue to build to continue Gap. E A I AE M :
M Develop Medicines Optimisation Optimisation Medicines Develop by Choosing supported Programme public the with conversation Wisely of Initial delivery Follow ups Programme county of Review Diagnostics Undertake in care of support urgent Programme Pain Pathways Initiate • • • •
P R OR A G M programme vision is provide to evidenceconsistent, based clinical services for the people of Gloucestershire, thatare supp KEY “Our “Our DELIVERABLES Reducing Clinical Variation will will Clinical Reducing Variation care, with primary approach on our variation in Outpatient in variation change a step deliver anda follow up promote care 'Choosing Wisely Optimisation Medicines and Gloucestershire' for Review. a Diagnostics undertake and approach, our will system set dialthe for This programme to close theand Care Quality
56 m
nd to NICE ‘Do ‘Do Do’ Not NICE to CARE & QUALITY GAP CARE & QUALITY re effective and prescribing re effective rimary care and greater provision of provision and care rimary greater Adherence Adherence recommendations of review of local findings Implement in Gloucestershire Practice Variation mo p care closer to home to closer care Greater consistency will reduce will consistency Greater care and unnecessary ineffective to patients provided care of experience patient Improved a diagnosis improved through treatment fro referrals appropriate More • • • • • - all
th G n of GCC ) tients but particularly those those wi but particularly tients HEALTH & WELLBEING GAP HEALTH omplex needs omplex pa c Improved medicines provision to medicines to provision Improved More effective and timely diagnosis effective More conditions of range a of through pain management Better medicines effective most of use athways for gastroenterology, for athways gainst metrics on the Medicines the on metrics gainst op decile performance op decile performance T (NHS Dashboard Optimisation England G to pathways new add to Continue urology, neurology, gynaecology, ENT and dermatology. Care website and monitorwebsite usage Care o instance in the first focusing a p • • • • • H O W T L W H I L C O I S E S L . . nd , so ups a ups - £21.7m & & EFFICIENCY GAP and 1,500 fewer A E & 1,500and fewer
FINANCE The overall impact impact of Reducing the The overall through Programme Variation Clinical in variation reduced primary care, medicines optimisation, achieving top decile in performance follow better use of diagnostics at upper at diagnostics use of better be would benchmarks decile elective 10,000 fewer approximately emergency admissions, 850 fewer admissions attendances. Delivering upperDelivering decile performance of a to saving equate would resource be will indicator key a in these areas utilisation • •
BENEFITS INDICATORS
57
5 -
YEAR 3
early stages.” rer outcomes for h respiratory and a enabling,positive, ts wit poo approach inequalities
eed to change our approach to
e n e life Further programme priorities will programme Further basedbe progressed on progress identified made and opportunities and benchmarking national through programme care right the across strategy education Embed for multiple CPGs system
• • care and effective long term conditionlong term effective and care -
YEAR 2
O B J E C T I V E : S
V I S I O N : I O N I S V Deliver new pathways for Circulatory and Circulatory for new Deliver pathways Programmes Clinical Diabetes health to addressing approach Develop inequalities across multiple CPGs Implementation of Implementation facing website patient • • • enhance quality of life for people across enhance peopleof quality across for life all social supporting groups,
Improve the health and wellbeing of our population and minimise minimise and of population our wellbeing and the health Improve we approach will work to thepathway of principleanFollowing entire moving care secondary their and conditions of term long management and diagnosis effective ensure To To ensure the best care is delivered within available resources, with an aim to move towards with an aim towards to resources, move available within is delivered care best the ensure To from carers and patients professionals, with engage will we approach pathway a care Through • management the to of end through right support, and of care experience • with a focus self on greater prevention, ‘upstream’, • prematurelydie who those reducing on a focus with communities, • To complications to reduce pressure on acute urgent services and health inequalities across our across inequalities health and services urgent on acute pressure reduce to complications ‘upper decile’ resource utilisation across utilisation as ‘upper across decile’ all resource described inprogrammes benchmarks national pathway our integrated and to transform across develop our system • • P R OR A G M M D EL E I V E R Y :
YEAR 1
active active - earlier and
science.
E A I AE M : , diagnosing,
implementation of Eye Health of Eye implementation
improvement improvement Complete and MSK Clinical Programmes Programmes Clinical MSK and Respiratory for new Deliver pathways andand Programmes Dementia Clinical based community new Cancer deliver model survivorship service models Implement integrated • • •
P R OR A G M M benchmarks benchmarks and aiming to the deliver right preventing disease
individuals) to one which is proactive, preventing disease, diagnosing earlier and treating and managing the condition from i
decile KEY diseasefrom that oneisreactive and waits people until develop severe(whichmore symptoms for the costNHS and resultsin “Our “Our programme vision is to work collaborativelyto drive the development of wholly clinicalintegrated services (commencing dementia) and deliveryofcare thatjoined issafe, up, accessible,evidence basedand bothclinically effective. and cost W DELIVERABLES The aim of the CPA is to deliver whole pathway whole pathway is deliver to The aim ofCPA the areas, programme clinical key across transformation Approach’ Programmes ‘Clinical utilising a structured of on based principles the best the deliver to be will priority A fundamental available, resources withinoutcomes possible care compared looking utilisation in ourat resource system to top to approach its early from the condition managing and treating stages. care, in the right place at the right time for the people people the for time right the at place right the in care, a pro will take it.need The programmes that
58 a r r targets y
Measures diagnosis replacement of asthma patients care - IAPT access targets of reviews Reported Outcome with diabetes diagnosed less diabetes with than diagnosed CARE & QUALITY GAP CARE & QUALITY pathways ar who attend a structured education ettingswherecurrently provided in atient eople More care provided in communit Better outcomesdue to care being provided intimely a way (in accordance Constitutionwith NHS standards) Reduced readmissions through provision of high quality care Parity ofesteemfor mentalhealth servicespatients and Greater support for patients and carers self providing in s acute care
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Improved mortality and morbidity rates through development of evidence based care pathways Reduced incidence and prevalence of preventable conditions due to investment in prevention Improved support for patients with long term conditions resulting in reduced services care acute to access • • • • • • • • • y H O W T L W H I L C O I S E S L . . g , y savin productivity
20m 20m £ decile
r & & EFFICIENCY GAP FINANCE missions, 3,900missions, elective admissions 25,000 fewer outpatient appointments outpatient fewer 25,000 Following Approach the ProgrammeClinical will see a the transformation in way that services are delivered. Our system has set a decile’ ‘upper to achieve target performance compared to similarsystems across a range of performance indicators. Delivering upper decile efficiencies and an to equivalent be would outcomes approximatereduction of 3,900emergenc ad 1 and 6,700 fewer A & E attendances b 2021. Achievement of of upper Achievement a to equivalent be would delivery of care patterns current against Resource of the 4 over STP. our years utilisationwill by programme therefore indicato be a key • • •
BENEFITS INDICATORS
59 Additional copies of this document are available from [email protected] To discuss receiving this information in large print or Braille please ring 0800 0151 548 To discuss receiving this information in other formats please contact:
Ak si želáte získat túto informáciu v inom formáte, kontaktujte prosím FREEPOST RRYY-KSGT-AGBR, Gloucestershire STP, Sanger House, 5220 Valiant Court, Gloucester Business Park Gloucester GL3 4FE
Publication date: Autumn 2016
60 Annex 2 - Short Guide
Developing Gloucestershire’s Sustainability and Transformation Plan (STP) Short Guide Developing our Sustainability and Transformation Plan
Introduction
This guide provides a summary of our local 5 year Sustainability and Transformation Plan (STP). It sets out the very significant challenges that we face and the opportunities we must take to ensure local people can access high quality, sustainable and safe, physical and mental health care into the future. Our approach builds on the foundations of our ‘Joining up your Care’ programme in 2014, which was subject to significant patient and public engagement. Moving forward, we believe we need to place greater emphasis on prevention of illness, support more self-care, provide more joined up care and support in the community and look at how some of our hospital services are organised to ensure safety and quality. We cannot make future changes alone and we would really like to hear your views on our approach. We will now begin a period of staff and public engagement over our STP priorities (see page 10). Following this, we will develop detailed proposals for consultation, as appropriate, in 2017/18. We would also encourage you to read our full STP which can be found at: www.gloucestershireSTP.net
NHS Gloucestershire Clinical Commissioning Group Gloucestershire Care Services NHS Trust 2gether NHS Foundation Trust Gloucestershire Hospitals NHS Foundation Trust South Western Ambulance Service NHS Foundation Trust Gloucestershire County Council
Our challenges ÆÆ Growing population (see opposite) with more complex needs, in all age groups ÆÆ Increasing demand for services and rising public expectations ÆÆ Encouraging greater personal responsibility – appropriate use of services and greater control of our own health, and that of our family ÆÆ Rising cost of drugs and new medical technology ÆÆ Recruiting and retaining enough staff with the right skills and expertise ÆÆ Pressure on finances (see opposite).
What we want to achieve A healthier population which is: ÆÆ Less dependent on health and social care services ÆÆ Living in more active communities – with strong networks of community support ÆÆ Able to access consistently high quality, safe, physical and mental health care when needed. 2 Registered population (2015) 632,500 +42,000 Projected rise
Projected population (2030) 674,500
Current no. of people over 65 with a long term condition 2,653 km2 47,500 Area covered by the STP 77,000 Projected rise by 2030
The increase in the 20% 75–84 age group by 2021
Total gap over the next 4 years (from 2017/18) unless we change the £226m* way we deliver services and support
* To meet the needs of local people, we think we need to spend more money on priority areas like GP services and mental health and fund vital new drugs and treatments. To do this, we will need to change the way we provide care and support. 3 What you have already told us: We sought local people’s views in 2014 (Joining up your Care) and this is what you told us then:
of respondents 93% generally agreed:
The ideas and new ways of working described in Joining up your Care could meet the challenges described. This included: greater focus on prevention and self-care, developing joined up community health and social care teams and services, bringing some specialist hospital services together in one place to ensure safety and quality
of respondents 78% generally agreed: A greater amount of the health and care budget should be spent on supporting people to be more in control of their own care and to stop them from becoming unwell, even if it meant there is less money spent on hospital based care
of respondents 95% generally agreed: Health and care services should ensure that they care for people who have the greatest health and care needs, regardless of where they live in Gloucestershire
4 Our STP approach
How can we help people and Enabling Active Communities communities to stay healthy?
We believe that there should be a far greater emphasis on self-care and prevention and community support. Working with our partners we have developed a plan 93% with investment to support this. Our approach will include: ÆÆ Supporting people with non-medical needs through social prescribing i.e. GPs referring to sources of community support and community activities ÆÆ Developing a county-wide programme to tackle obesity Æ Æ Promoting healthy workplaces Social Prescribing scheme success and schools, including improving employee health through the Joint working between the NHS, local workplace well-being charter councils and voluntary and community 78% organisations has meant that over 2,500 ÆÆ Using innovative technologies to people across the county have already support self-care e.g. Diabetes been helped to connect to support and ÆÆ Strengthening support for Carers. activities in their communities to help improve their well-being. “It turned my life around, from having no hope; I now have a huge range of people I can turn to for help.” 95%
5 How can we better organise One Place, One Budget, One System services and support?
We believe that wherever possible, care should be provided in the person’s own home, in the GP surgery or in the community. Where people have more serious illness or injuries, they should receive treatment in centres with the right facilities to maximise chances of survival and recovery. Our approach will focus on: The ‘People and Place’ community model ÆÆ GP practices at the core, working with health, social care and the voluntary and community sector, covering populations of around 30,000 ÆÆ GP practices working together in closer partnership to provide a wider range of local services ÆÆ Other health professionals working more closely with GP practices e.g. clinical pharmacists, paramedics and mental health staff to support local people ÆÆ Joined up health and social care teams – more care in people’s own homes and in the community, supported by specialist staff if needed ÆÆ Development of Centres of Excellence for rehabilitation at a number of community locations. Development of a network of centres and services to meet people’s urgent care needs ÆÆ Improved access to GP services – including evenings and weekends ÆÆ Community based urgent care centres – bringing together increased access to GP care, out of hours services, diagnostic tests and minor injury and illness services ÆÆ Increased support from hospital based specialists in the community ÆÆ Continued development of high quality and joined up Mental Health Crisis services.
Joined up care – supporting people at home and in the community Over 8,000 people a month have been helped by health and social care community teams (ICTs) this year, providing extra support in familiar surroundings and reducing unnecessary hospital stays. Over 3,000 people received urgent care at home from the Rapid Response Service (response within 1 hour). ICTs are now forging closer relationships with mental health services and voluntary and community organisations. “I wasn’t looking for them to just do things for me; I was looking to them to teach me how to do things myself. That’s what they did.”
6 How can we better organise One Place, One Budget, One System services and support?
Development of Centres of Excellence at our two general hospitals
When you need specialist hospital services, our plan is to: ÆÆ Ensure specialist staff see enough patients to maintain their skills and the right number of staff are available 24/7 ÆÆ Speed up assessment and decision making about people’s treatment and onward hospital care ÆÆ Improve the patient environment ÆÆ Improve links between related services – making services more joined up.
To do this we believe we should continue to bring together some services to ensure quality and safety. Proposals relating to specific services have not yet been developed as these will be shaped by feedback we receive through the public engagement phase. Future proposals for significant service change would be subject to full public consultation during 2017/18.
Thirlestaine Court – improving quality of care Established with the aim of creating a centre of excellence for breast screening, diagnosis and care of breast cancer patients, Thirlestaine Court, Cheltenham brings these services together under one roof. Treatment for breast cancer has seen great improvements in recent years, with more patients living longer. Success is due to earlier diagnosis, improved screening and professional expertise. Centralising care on one site has played an important part in this success story locally. “The level of care and compassion is exceptional. The staff are thoughtful, supportive, knowledgeable and caring - you realise you are in the best possible hands.”
7 How can we best develop Clinical Programme Approach services together?
We believe that we can continue to improve people’s experience of care through our clinical programme approach. Each Clinical Programme Group (CPG) covers a condition or group of conditions e.g. Cancer, Eye Health and involves medical and other professionals and patient representatives, including Healthwatch Gloucestershire, New Community Eye working together to improve the patient’s journey Service rolled out (pathway) through care. The service is already helping people This approach: receive the right care and advice closer to home through community opticians, ÆÆ Ensures care is safe, joined up and provides value often reducing the need to wait for for money hospital appointments. ÆÆ Places an emphasis on prevention and self- The development includes new services management advice at an early stage for glaucoma, cataracts, minor eye conditions and children’s services. ÆÆ Ensures people get the right treatment, in the right place, at the right time “I received excellent information, which put me at ease. I was very impressed ÆÆ Focuses on local priorities, including respiratory with the service and treatment.” care (e.g. lung disease) and dementia.
How can we reduce waste Clinical Variation and make best use of resources?
We believe we have a responsibility to use resources wisely and prioritise how our money is used. Our approach will include: ÆÆDeveloping a ‘Best use of medicines’ programme – helping people take the right Reducing inhaler waste medicines correctly to benefit their health, Half a million prescriptions a year are issued for avoid taking unnecessary medicines and inhalers across Gloucestershire at a cost of £10 million. reduce waste Poor inhaler technique reduces the amount of each ÆÆPriority funding the drugs and treatments inhaler ‘puff’ that reaches the lungs and increases that have the greatest health benefit for our medication waste. population Pharmacists and nurses are now actively identifying patients using high numbers of inhalers and offering ÆÆCampaigns highlighting how the public can inhaler technique reviews, re-education and training. help – e.g. choosing alternatives to A&E A lower cost brand of an equivalent inhaler may be when it’s not an emergency, cancelling prescribed if suitable for the patient. appointments if we can’t make them or not “Helping patients to more effectively use their inhalers stockpiling medicines leads to; increased drug reaching the lungs; reduced number of inhalers needed; and more cost ÆÆReducing duplication and improving service effective control of their condition.” efficiency e.g. looking at how we provide tests Practice Pharmacist and follow up outpatient appointments.
8 How can we develop Organisational Development and support our workforce?
We believe it is vital that we develop a sustainable health and care workforce, including GP practice staff, nurses, therapists and hospital doctors. Our approach will include: ÆÆ Offering county-wide leadership, training, County-wide approach to education and learning opportunities to dementia education support new ways of working and ensure The Gloucestershire Dementia Education Team staff have the right skills is now delivering education and training across ÆÆ Joining up teams and introducing new the health and social care workforce as well as volunteer and community organisations. roles to improve continuity of care and support for people The approach ensures that staff and partners have the knowledge and skills to support people living ÆÆ Joining up our approach to recruitment: with dementia and support the development of promoting Gloucestershire as a great dementia friendly communities. place to live and work “If you want to make a difference in your ÆÆ Minimising the use of expensive agency workplace for people with dementia this and temporary staff. course is a must.”
How can we make the most of new technologies?
We believe that technology has great potential to improve care through better information sharing, helping people to take more control over their health and helping them to access the right services and community support when needed. Mapmydiabetes Our approach will include: Over 12,000 adults with type 2 diabetes at 30 GP practices in Gloucester and the Forest ÆÆ Joining up your Information – secure access to of Dean can now benefit from this structured patient records for clinicians and care workers, online education tool. where and when they are needed It increases people’s understanding of Diabetes ÆÆ Providing access for patients and their carers and gives them the skills and confidence to to their digital health records manage their condition. ÆÆ Helping people to take greater responsibility All newly diagnosed diabetes patients in those for their health through use of technology areas will also be offered Mapmydiabetes and it will be rolled out county-wide from January ÆÆ Developing on-line resources to guide people 2017. through their care and treatment, including “Appointments with the practice nurse were by community support information week, now we’re looking at months, and the ÆÆ Extending the role of technology to support amount of time I spend with her is much less.” direct patient care e.g. e-consultations and video consultations.
9 Tell us what you think We want everyone to be able to have their say and know that their voice will be heard. There are a number of ways that you can give your views: Completing the Freepost survey below (or on-line at www.gloucestershireSTP.net) Sending an email to: [email protected] Visiting the Information Bus (see the website for details). Please share your views by 24 February 2017. Survey As part of our Joining up your Care conversations in 2014, people agreed a set of 1 principles. Do you think these still apply today?
Don’t Yes No know
A greater amount of the budget should be spent on supporting people to take more control of their own health
There should be a greater focus on prevention and self-care
We should develop joined up community health and care services
We should bring some specialist hospital services together in one place
We should focus on caring for people with the greatest health and care needs
When resources are limited, we think the NHS and care services need to prioritise 2 them. Rank the following in order of importance, where 1 is the most important to you
1 2 3 4 5
Caring for people in their own homes, or near to where they live
Funding additional community services by reducing the number of hospital beds in the future
Investing in health promotion – helping people to stay well for longer
Prioritising the funding of drugs and treatments that have the greatest health benefit for the population
Treating people with the most complicated health conditions 10 We think hospital beds should be available for patients requiring medical and 3 nursing care that cannot be provided elsewhere. Do you agree that hospital beds should not be used for people...
Strongly Strongly Agree Disagree Agree Disagree
Who no longer need hospital nursing or medical care
Who feel lonely or isolated
Who have medical needs that can be met at home, or in a care home Whose family feel unable or are unwilling to look after them
If you need to see a specialist (e.g at an outpatient clinic), the most important 4 thing to you would be: (choose one of the following)
The time I have to wait for an appointment
The distance I have to travel
The expertise of the specialist I see
Having as few appointments as possible
If you need urgent or emergency care services, the most important thing to you 5 would be: (choose one of the following)
Ability to access services 7 days a week
Centres/services staffed by specialists in dealing with your illness or injury
The distance I have to travel
Prompt assessment and decision making about my treatment and onward care Services that are joined up and can access information about my health and care needs
11 Please use the space below to make any further comments about our plan, tell 6 us what is important to you or share your own ideas for transforming health and care services in Gloucestershire
If you would like us to keep in touch with you and inform you of other ways you 7 can have your say, please provide your email contact details below (or postal address if preferred)
These questions are optional, but to help us ensure we reach a good cross-section of the local population, we About you... would be grateful if you could complete the following: Th 1 Are You Male Female Prefer not to say 2 Age group
Under 18 18-25 26-35 36-45 46-55 56-65 66-75 over 75 Prefer not to say
3 What is the first part of your postcode? eg. GL1, GL20
4 Overall, how would you rate your health during the past 4 weeks?
Excellent Very good Good Fair Poor Very Poor Prefer not to say 5 Are you: A health or social care professional A community partner/member of the public
Please return your survey, using the Freepost address below: To discuss receiving this information in large print or Braille please ring 0800 0151 548 To discuss receiving this information in other formats please contact:
Ak si želáte získat túto informáciu v inom formáte, kontaktujte prosím FREEPOST RRYY-KSGT-AGBR, Gloucestershire STP, Sanger House, 5220 Valiant Court, Gloucester Business Park Gloucester GL3 4FE
Publication date: Autumn 2016 12 Annex 3 - Memorandum of Understanding
24th October 2016
1. Gloucestershire Care Services NHS Trust 2. Gloucestershire Clinical Commissioning Group 3. Gloucestershire County Council 4. Gloucestershire Hospitals NHS Foundation Trust 5. South Western Ambulance Service NHS Foundation Trust 6. 2gether NHS Foundation Trust
MEMORANDUM OF UNDERSTANDING FOR THE DEVELOPMENT OF GLOUCESTERSHIRE’S SUSTAINABILITY AND TRANSFORMATION PLAN
Version No Date Author Number 1 01.04.16 1 JRK 2 17.05.2016 0.02 KM 3 26.5.2016 0.03 HE 4 27.5.2016 0.04 HE 5 27.5.2016 0.05 PJ and HE 6 13.06.2016 0.06 HE 7 23.06.2016 0.07 HE and KM 8 08.07.2016 0.08 HE 9 29.07.2016 0.09 HE/DL 10 07.09.2016 0.10 PJ/KM 11 22.09.2016 0.11 SML/ALD 12 28.09.2016 0.12 KM 13 04.10.2016 0.13 HE/CL 14 13.10.2016 0.14 HE/PJ/ER/AP 15 24.10.2016 0.15 KM/PJ 16 27.10.2016 0.16 FINAL KM Note: This MOU has been produced in partnership with Capsticks Solicitors LLP model CONTENTS
1. Definitions and interpretation ...... 4 2. Purpose and effect of MoU ...... 4 3. Key Objectives and Outcomes for the Project ...... 5 4. Principles of collaboration ...... 5 5. Governance and reporting ...... 6 6. Information Sharing and Information Governance ...... 8 7. Complaint, Claims and Requests (including Freedom of Information) ...... 8 8. Clinical Governance in integrated services ...... 9 9. Communications and Publicity ...... 10 10. Escalation ...... 10 11. Intellectual property ...... 10 12. Shared Resources to deliver the STP ...... 11 13. Procurement and contracting principles ...... 11 14. Term and termination ...... 11 15. Variation ...... 12 16. Charges and liabilities ...... 12 17. No partnership ...... 12 18. Counterparts ...... 12 19. Governing law and jurisdiction ...... 12 2 Signature ...... 13
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JOINT STATEMENT The Parties share the objectives of facilitating high-quality care for all and improving patient outcomes both now and in the future through joint working to provide clinically effective and cost-effective practice. We are all working to a common goal of providing the best care for our patients within the resources available to us. The Parties support the ambition set out in the Gloucestershire STP using a system of collaborative leadership to “take decisive steps to break down the barriers in how care is provided” and the rapid adoption and diffusion of the best, transformative, most innovative ideas, products, services and clinical practice for the people of Gloucestershire.
RECITALS 1. The Five Year Forward View published in October 2014 (the “Forward View”) sets out a clear goal that “the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care.” 2. Following a review of health and social care services in 2014, Gloucestershire CCG set out its five year plan; “Joining Up Your Care” (“JUYC”) to improve the quality of care for patients living in Gloucestershire. The Parties are committed to enabling individuals to take greater control of their health and wellbeing through delivering greater patient support in patients’ homes and local communities. 3. The Parties’ shared vision is to improve health and wellbeing by working better together in a more integrated way and using the strengths of individuals, carers and local communities to transform the quality of care and support provided to people living in Gloucestershire. 4. In entering into and performing their obligations under this memorandum of understanding, the Parties are working towards the implementation of the integrated care models highlighted in the Forward View. In particular, this memorandum of understanding is intended to support the Parties’ ongoing work towards the
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establishment of a model of integrated health and social care services in Gloucestershire. This model will build upon the ambitions set out in the Sustainability and Transformation plan (building on the JUYC five year plan).
OPERATIVE PROVISIONS 1. Definitions and interpretation 1.1 In this MoU, capitalised words and expressions shall have the meanings given to them in this memorandum of understanding (the “MoU”). 1.2 In this MoU, unless the context requires otherwise, the following rules of construction shall apply: 1.2.1 a person includes a natural person, corporate or unincorporated body (whether or not having separate legal personality); 1.2.2 a reference to a “Party” is a reference to a party to this MoU and includes its personal representatives, successors or permitted assigns and a reference to “Parties” is a reference to all parties to this MoU; 1.2.3 a reference to a statute or statutory provision is a reference to such statute or provision as amended or re-enacted. A reference to a statute or statutory provision includes any subordinate legislation made under that statute or statutory provision, as amended or re-enacted; 1.2.4 any phrase introduced by the terms “including”, “include”, “in particular” or any similar expression shall be construed as illustrative and shall not limit the sense of the words preceding those terms; 1.2.5 documents in “agreed form” are documents in the form agreed by the Parties and initialled by them for identification and attached to this MoU; and 1.2.6 a reference to writing or written includes faxes and e-mails. 2. Purpose and effect of MoU 2.1 The Parties have agreed to work together on the development of more integrated care for service users in line with the Gloucestershire STP (the “Gloucestershire STP”). 2.2 The MoU provides further detail with respect to the components of the priority programmes of work, to be supplemented by the accompanying schedules for each programme of work, which will be incorporated into this MoU in accordance with clause 15.2. 2.3 The Parties wish to record the basis on which they will collaborate with each other on the Gloucestershire STP. 2.4 This MoU sets out: 2.4.1 the key objectives of the Gloucestershire STP; 2.4.2 the principles of collaboration; 2.4.3 the governance structures the Parties will put in place; and 2.4.4 the respective roles and responsibilities the Parties will have during the Gloucestershire STP.
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2.5 The Parties agree that, notwithstanding the good faith consideration that each Party has afforded the terms set out in this MoU, this MoU shall not be legally binding. 3. Key Objectives and Outcomes for the Project 3.1 The Parties shall support the Gloucestershire STP to achieve the key objectives set out below (the “Key Objectives”). The long-term ambition is to have a Gloucestershire population, which is: • Less dependent on health and social care services; • Living in healthy communities and benefitting from strong networks of community support; and • Able to access high quality care when needed in the right place, at the right time. 3.2 In addition the Parties will work together through the following principles: • We will ensure commitment to a risk share approach aligned to our priorities. This should be underpinned by an open, transparent approach to the development of opportunities for change; • We will commit to the principles of 'One Place, One Budget, One System' to improve services and outcomes for our population, whilst working to ensure financial stability across our system; • We will work to the principle of moving care ‘upstream’, and will be aiming to prioritise resources within our care pathways towards primary care and prevention where possible; • We will work to the principle of commissioning through a care pathways approach, and within commissioned pathways we will work together to identify opportunities for increased cost effectiveness, minimising the number of steps and driving greater efficiency; • We will consider whether the pilot(s) of innovative organisational forms in line with the Forward View new models for delivery of care will require us to develop any new organisational forms or innovative approaches to contracting; • We will not commission or provide services that are deemed by evidence to not be cost-effective or clinically effective; and • We will endeavour to minimise our infrastructure costs by sharing facilities and support wherever it is feasible and represents value for money. 3.3 The Parties acknowledge that the current position with regard to the Gloucestershire STP framework is set out within this MoU. Programmes of work will utilise schedules, to be incorporated into this MoU in accordance with clause 15.2. 4. Principles of collaboration 4.1 The Parties agree to adopt the following principles when carrying out the Gloucestershire STP: 4.1.1 collaborate and co-operate. Establish and adhere to the governance structure set out in this MoU to ensure that activities are delivered and actions taken as required;
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4.1.2 be accountable. Take on, manage and account to each other for performance of the respective roles and responsibilities as referred to within this MoU; 4.1.3 be open. Communicate openly about major concerns, issues or opportunities relating to the Gloucestershire STP; 4.1.4 adhere to statutory requirements and best practice. Comply with applicable laws and standards including EU procurement rules, competition law, data protection and freedom of information legislation; 4.1.5 act in a timely manner. Recognise the time-critical nature of the Gloucestershire STP and respond accordingly to requests for support; 4.1.6 work constructively with stakeholders with the aim of securing their support for the Gloucestershire STP and its delivery; 4.1.7 deploy appropriate resources. Ensure sufficient and appropriately qualified resources are available and authorised to fulfil the responsibilities set out in this MoU; and 4.1.8 act in good faith to support achievement of the Key Objectives and compliance with these Principles. 5. Governance and reporting 5.1 The programme structure defined below provides the governance approach for the development and delivery the Gloucestershire STP 5.2
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5.3 The parties agree to act in accordance with the principles of decision-making set out in Schedule 1 to this MoU.
5.4 As defined within the King’s Fund’s 10 overarching principles of integration within a place based care model 1we will • Define the population group served and the boundaries of the system; • Identify the right partners and services that need to be involved; • Develop a shared vision and objectives reflecting the local context and the needs and wants of the public identified through feedback and engagement; • Develop an appropriate governance structure for the system of care, which must meaningfully involve patients and the public in decision-making; • Identify the right leaders to be involved in managing the system and develop a new form of system leadership; • Agree how conflicts will be resolved and what will happen when people fail to play by the agreed rules of the system; • Develop a sustainable financing model for the system across three different levels: 1. the combined resources available to achieve the aims of the system; 2. the way that these resources will flow down to providers; 3. how these resources are allocated between providers and the way that costs, risks and rewards will be shared; • Create a dedicated team to manage the work of the system; • Develop ‘systems within systems’ to focus on different parts of the group’s objectives; and • Develop a single set of measures to understand progress and use for improvement.
1 Ham, C., and Alderwick, H. (2015). Place based systems of care: A way forward for the NHS in England. Kingsfund.
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6. Information Sharing and Information Governance 6.1 The Parties: 6.1.1 acknowledge that they are statutory bodies subject to primary and secondary legislation and guidance; and 6.1.2 agree that the provisions of this clause 6 are subject always to the Parties’ statutory obligations under competition law and procurement law. 6.2 The Parties will freely share business and anonymised information to support integration and transformation discussions where such sharing is in the best interests of patients. There will be total transparency between us in sharing information on operational pressures, quality issues and finance. 6.3 Key system wide measures will be agreed and shared with all Parties to include activity, finance, workforce and outcomes. In addition programmes will have specific requirements which will be detailed in the Schedules. 6.4 All parties will ensure that any sharing of personal identifiable data is compliant with information governance requirements and is covered by the Gloucestershire Information Sharing Partnership Agreement. 7. Complaint, Claims and Requests (including Freedom of Information) 7.1 The Parties acknowledge that the provisions of this clause 7 are subject always to the Parties’ obligations set out in primary and secondary legislation and guidance. 7.2 If any Party receives any formal inquiry, complaint, claim or threat of action from a third party (including, but not limited to, claims made by a supplier or requests for information made under the Freedom of Information Act 2000 (“FOIA”)) in relation to the Gloucestershire STP, the matter shall be promptly referred to the STP Programme Director. 7.3 The Parties acknowledge and confirm that no action shall be taken in response to any inquiry, complaint, claim or action as described in paragraph 7.2 above, to the extent that such response would adversely affect the Gloucestershire STP, without the prior approval of the STP Delivery Board (led by an independent chair). 7.4 Each Party acknowledges that the other Parties are public authorities for the purposes of FOIA. 7.5 Each Party may be statutorily required to disclose information about the MoU in response to a specific request under FOIA, in which case: 7.5.1 each Party shall provide the others with all reasonable assistance and co- operation to enable them to comply with their obligations under FOIA; 7.5.2 each Party shall consult the others regarding the possible application of exemptions in relation to the information requested; and 7.5.3 each Party acknowledges that the final decision as to the form or content of the response to any request is a matter for the Party to whom the request is addressed.
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8. Clinical Governance in integrated services 8.1 Parties have agreed that clinical governance comprises 3 separate elements: 8.1.1 Clinical Accountability for the Service This is an organisational responsibility which would include but not be limited to: • developing the clinical governance framework; • developing and maintaining protocols of care; and • developing the competency framework for staff delivering the service. 8.1.2 Operational Management of the Service This is an organisational responsibility which would include but not be limited to: • Application of governance and competency frameworks; • Reporting on compliance with the protocols and frameworks; • Management of staff; and • Supporting the role of the lead clinician.
8.1.3 Clinical Accountability for the Patient It is recommended that the term lead clinician is adopted across all services.
• The role includes overall responsibility for the management, coordination and continuity of a patient’s care. The lead clinician will also be likely to have some direct personal clinical responsibility for the patient. • The role does not undermine the concept of multidisciplinary team (“MDT”) care and working, where many clinical decisions arise. It is paramount that the multidisciplinary team and the lead clinician work together to ensure all the links are made to enable safe and appropriate coordination of care. Team members within the MDT will be expected to continue to give appropriate advice. It is not intended that all issues are automatically referred to the lead clinician. • The lead clinician is the person to whom a patient or their relative/carer would ultimately address concerns about any aspect of care. This means they will take overall responsibility for ensuring that any clinical issues, reports of specialised tests or investigations, difficulties or complaints are addressed appropriately. 8.2 What does this mean in practice Seamless clinical pathways inevitably require that a patient’s care be transferred between individuals, teams and organisations. It is vital that the accountabilities for all the stages above are clearly assigned and recognised at all stages of a pathway. The assignment of roles in any pathway should have regard to: • the competence and capacity required to fulfil the roles • minimising the number of transitions in any pathway • ensuring the lead clinician is recognised and legitimised in the organisation with operational accountability • that fulfilling the role of lead clinician should be recognised in the planning and resourcing of the individual’s workload and activity.
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9. Communications and Publicity 9.1 The Parties will ensure a joint approach to communications; agreeing key messages and authorising the approach through the STP Delivery Board. 9.2 It will be the role of the STP Delivery Board to make an assessment on whether changes are likely to constitute a substantial service change, requiring consultation under applicable legislation (including, but not limited to, Section 14Z2 and Section 242(1B) of the National Health Service Act 2006 (as amended)) and advise on the process accordingly. 9.3 The Parties accept responsibility for the cascade of agreed messages within their own organisations.
10. Escalation 10.1 If any Party has any issues, concerns or complaints about the Gloucestershire STP, or any matter in this MoU, such Party shall notify the other Parties and the Parties acknowledge and confirm that they shall then seek to resolve the issue by a process of discussion. 10.2 If an issue identified in accordance with paragraph 10.1 above cannot be resolved within a reasonable period of time, the matter shall be escalated to the STP Programme Director who shall decide on the process to take for resolution. 10.3 If the matter cannot be resolved by the STP Programme Director, within five Operational Days (an “Operational Day” being a day other than a Saturday, Sunday or bank holiday in England), the matter shall be escalated to the STP Delivery Board (led by an independent chair) for resolution. 10.4 Subject always to the Parties’ statutory decision-making constraints, where any matter is not resolved under clauses 10.1, 10.2 or 10.3 above, any Party or the STP Programme Director may refer the matter for mediation arranged by an independent third party to be appointed by the STP Delivery Board. Any agreement reached through mediation must be set out in writing but will be non-binding on the Parties. 10.5 Any issues, concerns or complaints with regards to the schedules should be discussed within the work programme for which it relates. If an issue cannot be resolved it should be escalated to the relevant programme board within the Gloucestershire STP governance structure. 11. Intellectual property 11.1 The Parties intend that any intellectual property rights created in the course of the Gloucestershire STP shall vest in the Party whose employee created them (or in the case of any intellectual property rights created by employees of more than one Party, in the Party that is lead party for the part of the Gloucestershire STP that the intellectual property right relates to). 11.2 Where any intellectual property right vests in any one Party in accordance with the intention set out in paragraph 11.1 above, that Party shall grant a royalty free irrevocable licence to the other Parties to use that intellectual property for the purposes of the Gloucestershire STP.
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12. Shared Resources to deliver the STP 12.1 The Parties will commit to the principles of the Gloucestershire STP (as listed in section 3.2) to improve services and outcomes for our population, whilst working to ensure financial stability across our system. 12.2 The Parties will provide non financial support to ensure a dedicated team is in place to deliver the components of the Gloucestershire STP under the collaborative leadership model. 12.3 Except as otherwise provided, the Parties shall each bear their own costs and expenses incurred in complying with their obligations under this MoU including in respect of any losses or liabilities incurred due to their own or their employee's actions. 12.4 Any costs associated with STP delivery will be transparent and overseen by the STP Delivery Board 13. Procurement and contracting principles 13.1 Section 7 of the Gloucestershire CCG operating plan for 2016/17 outlines the intended procurements for the year. (Gloucestershire STP does not envisage any addition to these priorities within the same time period). Gloucestershire STP work streams will be required to flag any risk to this through the agreed governance structure, including where any provider procurement would impact on the Gloucestershire STP. Intended procurements for 2017/18 will be considered once known. 13.2 2017/18 is the first year of our System Transformation and the decisions we take in setting 2017/18 contracts will be consistent with our STP (or at the very least not taking us in the wrong direction). 13.3 There is one pot of money and our collective task is to get the best value from that pot. Our aim will be to maximise the value and take out high cost, low value activity where possible. 13.4 We will agree the priorities for improving the quality of services and the resources to be invested in these priorities. 13.5 Our investment decisions will be consistent with our STP. 13.6 Investment (defined as funding above 2016/17 plans) is dependent on agreed service changes being identified and delivered. 13.7 Each organisation will achieve the financial control totals which are set by regulators. For the CCG this will be to achieve a 1% surplus. 13.8 Financial risk in year will be a shared responsibility. 13.9 There will be a shared responsibility for redesigning pathways. 14. Term and termination 14.1 This MoU shall commence on the date of signature by all the Parties, and shall be in place for a period of 12 months. 14.2 Any Party may terminate this MoU by giving at least three months' notice in writing to the other Parties.
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15. Variation 15.1 This MoU may only be varied by written agreement of the STP Delivery Board. 15.2 The Parties acknowledge and agree that, as at the date of this MoU, the details of the Gloucestershire STP programmes of work are still to be agreed. The STP Delivery Board shall agree in writing the detail and components of each programme of work and, once agreed: 15.2.1 the detail of each programme of work shall be signed by an authorised representative of each Party; and 15.2.2 on the date that a programme of work is signed by an authorised representative of each Party, this MoU shall have effect as though the agreed programme of work had been originally contained in this MoU as a schedule and the MoU shall be amended accordingly. 16. Charges and liabilities 16.1 There will be transparency over any gain or loss attributable to any individual Party, whilst working to ensure financial stability across our system. 16.2 Whilst each Party shall be responsible for its own costs and liabilities, the system will work collectively to manage these during the transitional phase. 17. No partnership 17.1 Nothing in this MoU is intended to, or shall be deemed to, establish any partnership or joint venture between the Parties, constitute any Party as the agent of any other Party, nor authorise any of the Parties to make or enter into any commitments for or on behalf of the other Parties. 18. Counterparts 18.1 This MoU may be executed in any number of counterparts, each of which when executed and delivered shall constitute an original of this MoU, but all the counterparts shall together constitute the same agreement. 18.2 The expression “counterpart” shall include any executed copy of this memorandum of understanding transmitted by fax or scanned into printable PDF, JPEG, or other agreed digital format and transmitted as an e-mail attachment. 18.3 No counterpart shall be effective until each Party has executed at least one counterpart. 19. Governing law and jurisdiction 19.1 This MoU shall be governed by and construed in accordance with English law and, without affecting the escalation procedure set out in section 10, each Party agrees to submit to the exclusive jurisdiction of the courts of England and Wales.
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______Signed on behalf of Gloucestershire Clinical Commissioning Group
______Signed on behalf of Gloucestershire County Council
______Signed on behalf of Gloucestershire Hospitals NHS Foundation Trust
______Signed on behalf of South Western Ambulance Service NHS Foundation Trust
______Signed on behalf of 2gether NHS Foundation Trust
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SCHEDULE 1: PRINCIPLES OF DECISION-MAKING
1. Principles of decision-making
1.1. The Parties will:
1.1.1. collaborate in accordance with the principles set out in this MoU to enable the development and delivery of the Gloucestershire STP;
1.1.2. take into account their statutory constraints and parameters, acknowledging that they are all separate statutory bodies subject to primary and secondary legislation and guidance as detailed in Appendix 1 (Constraints on Parties’ Decision-Making); and
1.1.3. taking into account their statutory constraints and flexibilities, work together for the benefit of the health and social care economy in Gloucestershire as a whole taking into account patients and the public in the wider area.
1.2. The Gloucestershire Strategic Forum (GSF) and the STP Delivery Board shall operate to advise, co-ordinate and facilitate decision-making between the Parties in support of the Gloucestershire STP.
1.3. Notwithstanding clauses 1.1 to 1.2 above, the Parties acknowledge and agree that:
1.3.1. no statutory functions or powers are being delegated by any Party to any other Party under this MoU;
1.3.2. each Party remains responsible and accountable for its statutory responsibilities and nothing in this MoU is a divestment or delegation of any Party’s decision-making powers; and
1.3.3. accordingly, the Gloucestershire Strategic Forum and the STP Delivery Board do not have delegated responsibility to make decisions that bind the Parties.
1.4. The Parties acknowledge that, depending on the subject matter of the STP programmes of work in question, some or all of the Parties may be required to make a statutory decision in respect of implementation of that programme of work and that, in order to act efficiently and effectively, it is important to take into account the various statutory roles and responsibilities at an early stage. Accordingly, the Parties will, in respect of each programme of work, review the table set out in Appendix 2 (STP Programme of Work: Role and Relevant Approvals) and use the outcome of that review to ensure that the relevant Parties are engaged and involved at the appropriate times and stages in order to ensure that decisions are reached timeously and collaboratively.
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Appendix 1 Constraints on Parties’ Decision-Making
Constraints on Decision-Making
NHS Commissioners National Health Service Act 2006 (as amended) and related legislation
CCG constitution
Procurement law
Guidance for commissioners, including on conflicts of interest and reconfiguration
Case law
Local Authorities Local Government Act 1972 and related legislation
National Health Service Act 2006 (as amended) and related legislation
Procurement law
Competition law
NHS Providers National Health Service Act 2006 (as amended) and related legislation
NHS provider licence / Foundation Trust constitution and/or SOs/SFIs
Procurement law
Competition law
Guidance for providers, including from NHS Improvement
Case law
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Appendix 2 STP Programme of Work: Role and Relevant Approvals
[Insert name and nature of programme of work]
Gloucestershire Gloucestershire Gloucestershire Gloucestershire 2gether CCG County Council Care Services Hospitals NHS NHS NHS Trust Foundation Foundation Trust Trust
Role [insert details] [insert details] [insert details] [insert details] [insert (including details] meeting and support)
Internal [insert details] [insert details] [insert details] [insert details] [insert approvals details] process and governance issues (if any)
External [insert details] [insert details] [insert details] [insert details] [insert approvals details] process (if any)
Key dates to [insert details] [insert details] [insert details] [insert details] [insert note details]
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Agenda item 11 Governing Body
Meeting Date Thursday 24th November 2016
Title 2017/18 Planning Round Update
Executive Summary This paper provides a progress update on a shortened planning round during which the CCG has published Sustainability and Transformation Plan (STP) and is in the process of drafting an aligned 2 year Operational Plan.
The paper provides an update on a number planning items including :
- mid year review of progress in delivering the 2016/17 Operational Plan
- updated procedures and tools for supporting business case review and approval
Key Issues Ensuring consistency and alignment between the STP submission and the more detailed Operational Plan for 2017/18-2018/19
Addressing all requirements of NHS England including addressing the 9 ‘must-dos’
Ensuring adoption of updated procedures and tools for business case review and approval Risk Issues: Not Applicable Original Risk Residual Risk
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Financial Impact Achieving agreed financial control totals requires credible plans.
Legal Issues The Operational Plan addresses plans for (including NHS achieving a number of performance targets Constitution) outlined in the NHS Constitution.
Impact on Health The Operational Plan outlines, where Inequalities appropriate, how health inequalities will be reduced. Proposals within the Operational Plan require an impact assessment to be undertaken. Impact on Equality The Operational Plan outlines, where and Diversity appropriate, how equality and diversity issues will be addressed. Proposals within the Operational Plan require an impact assessment to be undertaken. Impact on Sustainable Proposals within the Operational Plan require Development an impact assessment to be undertaken. Patient and Public Individual proposals within the Operational Involvement Plan may have been subject to Patient and Public Involvement. The Operational Plan is aligned to the STP and Joining up Your Care (JUYC) which are subject to wider consultation. Recommendation The Governing Body are asked to note:
the progress made in delivering the 2016/17 Operational Plan; the 2017/18 planning timetable and key activities to date; the revised business case approval process; and the revised business case template. Author Ellen Rule Designation Director of Transformation and Service Redesign Sponsoring Director (if not author)
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Agenda Item 11
Governing Body Thursday 24th November 2016 2017/18 Planning Round Update
1. Introduction
1.1 The paper provides an update on a number planning items including :
- an overview of the 2017/18 planning round and key activities to date;
- a mid-year review of progress in delivering the 2016/17 Operational Plan; and
- Updated procedures and tools for supporting business case review and approval.
1.2 The 2017/18 Planning Round has differed from previous planning rounds in two significant ways :
I. The concurrent development of the STP and Operational Plan for 2017/18-2018/19 has provided a greater opportunity to ensure that mid term planning is closely aligned to commitments made within the STP.
II. The timescales for delivering the Operational Plan and agreeing provider contracts has been significantly foreshortened such that final deadlines for both are 23rd December rather than early April 2017.
1.3 As a consequence of the above this planning round is more intense than usual but provides a significant opportunity to develop aligned and credible mid and long terms plans.
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2. Planning Timetable
2.1 Below is the 2017/18 GCCG Planning Timetable that covers the development of the STP, the GCCG Operational Plan and contract deadlines:
DATE EVENT September 9th STP Assurance meeting 16th STP Finance re-submission 20th Publication of NHS planning guidance for 17/18 and 18/19 22nd Planning Guidance published Technical Guidance issued Commissioner Finance Template published Draft NHS Standard Contract and national CQUIN scheme guidance published Draft National Tariff Prices published 30th Providers submit contract intentions to GCCG First draft CCG internal budget plans 17/18 Provider control totals and STF allocations published Counting & coding notification received Counting & coding sent to key providers October 21st Commissioner allocations published NHS Standard Contract consultation closes STP whole re-submission (by organisation) 24th Confirm finance split by organisation as per STP submission for baseline 31st Updated draft CCG internal budget plan National Tariff Section 118 consultation issued Final CCG and specialised services CQUIN scheme guidance issued November 1st Provider finance, workforce and activity templates issued with related Technical Guidance (providers only) Submission of summary level 2017/18 to 2018/19 operational finance plans (noon) 4th Commissioners to issue initial contract offers that form a reasonable basis for negotiations to providers Final NHS Standard Contract published Provider finance, workforce and activity templates issued with related Technical
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Guidance (providers only) Awaiting confirmation from NHSE re dates – submission of UNIFY activity & QP w/c 7th 17/18 – 18/19 local prices received
11th Providers to respond to initial commissioner contract offer 24th Submission of full draft 2017/18 to 2018/19 operational plans (noon) 21st/22nd Weekly contract tracker to be submitted (weekly up to 31st Jan) December 5th Local decisions to enter mediation to be made – if contract sign deadline is at risk Contract Mediation (5th – 23rd) 6th National Tariff section 118 consultation closes w/c 12th National Tariff Section 118 consultation results announced 16th Contracts finalised for signature (final draft) 20th Publication of National Tariff 23rd Final Operational Plan submitted National deadline for signing of contracts
2017 January 2017 9th Submission of joint arbitration paperwork where contracts not signed Arbitration outcome notified to GGCs/providers Within two working days of panel date 31st Contract and schedule revisions reflecting arbitration findings completed and signed
3. Planning Activities to date (November 2016)
3.1 In line with the planning timetable described above, key planning activities undertaken to date include:
Submission of STP document to NHS England in October 2016, followed by publication alongside accompanying Short Guide and Survey in November 2016. STP finance and activity submissions in September and October 2016. Work to define key programmes of work and commitments for 2017/18-2018/19, to develop the draft
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Operational Plan, within the context of our STP priorities. Issue of initial contract offers to providers in line with the planning guidance from NHS England.
4. 2016/17 Operational Plan Review
4.1 In addition to providing an overview of the planning round this report also includes a stocktake of progress to date in delivering the 2016/17 Operational Plan (see Appendix 1). This mid-year review (6 months, April to October 2016) highlights the good progress made and sets the scene for areas of focus for the remainder of 2016/17.
4.2 The report provides an overview of planned actions to ensure a continued focus on delivery of our operational commitments, for programmes that have received Red or Amber RAG ratings for delivery at this 6 month checkpoint.
5. Business Case Approval Process
5.1 As a result of the new ways of working required to deliver the STP, key approval procedures and tools for delivering STP programmes are shown in Appendices 2-3. These include a revised Business Case template and new business case approval process.
5.2 This has been developed by PMO Lead representatives working in partnership to ensure a comprehensive, transparent and responsive process that is adhered to across the system, in order to support the principles set out in the STP Memorandum of Understanding.
6. Recommendations
6.1 The Governing Body are asked to note:
the progress made in delivering the 2016/17 Operational Plan; the 2017/18 planning timetable and key activities to date; the revised business case approval process; and
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the revised business case template.
7. Appendices
Appendix 1 : 2016/17 Operational Plan Delivery Update Appendix 2 : Business Case Template Appendix 3 : Business Case Approval Process
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Annex 1: NHS Gloucestershire CCG Operational Plan – Assessment of 2016/17 Programme Delivery
1) The 2016/17 Operational Plan set out our commitments to be delivered against our strategy, Joining Up Your Care, our ambitions to improve health and care across the Gloucestershire health community on behalf of our local population. This paper provides an overview of the delivery against our 2016/17 operational plan commitments across our programmes.
Table 1: High Level Summary Table:
Operational Plan Objective RAG Enabling Active Communities G Primary Care and Locality Development G Clinical Programme Approach G - Urgent Care A - Planned Care A Parity for Mental Health & Learning Disabilities: - Mental Health A - Dementia G - LD G Integration G Person Centred Care G System Sustainability A
Green 40 Amber 16 Red 2
2) Our Priorities for the next 6 months of our plan:
Table 2: Remedial actions to Red RAG schemes:
Red RAG Schemes Remedial Actions Continue to take steps to improve the access to Psychological Therapies, to ensure we meet the requirements of the IAPT national targets for access, recovery and wait times to treatment. We will continue to review the capacity available within the system and IAPT ensure the service model is responsive to the increasing demand. This will include the review of the existing staffing models across Mental Health services i.e. Mental Health Intermediate Care Team in terms of allocation of resource to see how this can further support the delivery of the IAPT service. Work with providers to produce a detailed recovery plan Constitution Standards in response to current and future demand planning that sets out the level of capacity the provider expects to need to deliver a sustainable constitution compliant performance in all areas, and to highlight where there are risks to delivery of core standards.
Table 3: Remedial actions for Amber rated schemes:
Amber Programme Remedial Actions Themes Moving at pace In order to maximise delivery in 2016/17 and moving forward there is a requirement to accelerate implementation of key schemes. Programme plans will continue to be developed across the STP priority areas to ensure that delivery is owned and driven at a system scale. This will enable efficient implementation and remove organisational barriers that lead to delays. Additionally highlight reporting across key programmes will ensure risks to delivery, gaps in resourcing and key issues to implementation will be quickly escalated to a STP Board level. Maintaining focus on As noted by the red RAG assigned to the constitution development priorities standards to be delivered by the local system, there are alongside constitution significant performance issues that have had an impact delivery on implementing transformational change – this has led to a number of amber ratings in key programmes. For example, key aspects of the Urgent Care programme have been impacted by demand and capacity issues, highlighted by ED 4 hour targets and ambulance performance. Managing programme Many of our operational commitments in 2016/17 interdependencies require a cross-cutting approach across key programmes. There have been noted amber ratings in key programmes, where the transformational approach required working across teams, but capacity and alignment of work-plans impacted on pace of delivery. We are currently working on embedding our approach to aligning transformational change priorities across our CCG teams, supported by aligned work plans in line with our STP priorities. Transformation at system Our 16/17 operational plan outlined our initial steps in level developing an STP for Gloucestershire. Therefore commitments were outlined across system enabling programmes that would require developing our STP to design and implement. Therefore in some instances i.e. enhancing the skills and knowledge of our workforce in order for them to be co-producers in health, were reliant on significant development of our Workforce and OD and Enabling Active Communities programmes. Whilst noted progress has been made, i.e. development of a system wide work force plan and commissioning Health@Work as part of the Workplace Wellbeing Charter, these commitments will remain a key focus of our 2017/18-18/19 Operational Plan, as part of the delivery of years 1 & 2 of our STP.
3) Table 4: Delivery Against Operational Plan Objectives at Mid-Year:
Enabling Active Communities What we said… What we have delivered… RAG Work with AHSN to Expression of interest submitted to NHSE to join Wave 2 of deliver Diabetes Self- the National Diabetes Prevention Programme has been G Management Programme successful and we have been selected as next wave, with at Scale funding provided to support roll out. Promote healthy lifestyles GCCG has supported GCC with the tender for a new as part of our care integrated Healthy Lifestyle Pathway. pathways and whole Commissioned local County Sport Partnership to support system approach linking and train primary schools to take up the ‘Daily Mile’ to public health initiative. commissioned and local We have continued to roll out Facts4Life across the county G council commissioned with 76 schools now having received training (target 96). services e.g. exercise on The initiative is currently being independently evaluated by referral and weight the University of the West of England management programmes; Commit additional Undertaken 12 test and learn projects as part of our cultural resources to invest in the commissioning programme. National report published by Voluntary Sector in the New Economics Foundation (NEF) showcasing the support of Self Care and work in Gloucestershire. Currently being evaluated by the G Prevention, and through University of Gloucestershire. our Cultural Commissioning work Simplify online access to Online patient facing website being developed. Work also information and services being undertaken to consolidate existing website provision A for our patients and around community based support as part of our STP Digital communities Road Map Work with our partners to Commissioned Health@work to roll out the Workplace enhance the knowledge Wellbeing Charter to 40 organisations across the county. and skills of our health 32 organisations to have been recruited by March 17, with workforce in order for 16 of those organisations having been accredited. them to become co- Commissioned Active Gloucestershire to increase physical producers in health activity levels of older adults across Gloucestershire A through peer activators, leaders and coaches. 10 volunteers (target is 60 by Sept 17)and 40 adults engaged (target is 1000 by Sept 17) Consensus statement being developed by commissioners and providers to support the implementation of system wide health coaching model Ensure effective Social prescribing now in place across 81 practices with utilisation of the well- approximately 1500 patients referred each year being services available Plans in place to procure a new social prescribing and at a locality level through community agents model to go live from April 17 G a co-ordinated approach CCG’s social prescribing scheme highlighted as good (social prescribing) practice within NHSCC’s ‘Delivering a Healthy Future’ report
Develop the role of A key partner within the AHSN collaboration leading on the assistive technologies NHSE Digital Test Bed supporting patients with diabetes to and innovative self-manage. This includes the implementation of two approaches innovative projects: Map My Diabetes – online structured education o G programme rolled out across the Gloucester and Forest of Dean localities. o Ki Performance – testing out the use of accelometry with a Hucclecote Practice, Gloucester. Expected to support 200 patients by Oct 2017 Work with our health We have been awarded free access by NHSE England for partners to standardise the Patient Activation Measure and currently our approach to operationalising the tool across three areas: COPD winter personalised care pressures scheme (3000 patients to be provided with a planning self-management plan and patient activation score leading to more personalised and tailored support), frailty G programme (Gloucester and South Cots) and MacMillan Next Steps. Further development of our Integrated Community Teams, forming part of the place based multi-disciplinary teams as part of the implementation of our 30,000 model. Increase utilisation of the Project initiated to improve smoking cessation for women in smoking cessation pregnancy as a key part of our health inequalities plan. service for patients prior Smoking audit undertaken within primary care to improve G to an elective operation data quality and support for smoker cessation. Results showed that approximately 80% of patients (15+) who were recorded as a ‘smoker’ were provided a brief intervention. Work with our partners Worked with our county council colleagues as part of the and providers to ensure a PHE/Leeds Beckett University programme around co-ordinated approach to developing a whole system approach to tackling obesity tackling obesity across Comprehensive work programme in place with the the county and the following service redesign workshops held in 2016: G development of seamless o Tier 3 specialist weight management services for care pathways adults o Tier 3 specialist weight management services for children o Tier 2 Weight management service for children
Primary Care and Locality Development What we said… What we have delivered… RAG Develop and agree the The Primary Care Strategy was developed and Primary Care Strategy subsequently approved in September 2016, including the (including Primary Care Primary Care Infrastructure and Workforce. G Infrastructure Plan, Primary Care Workforce Plan) Develop the role of The New Models of Care Board was established in 2016, G localities in leading delivery aiming to oversee the creation of new models of care that of Placed Based Plans can adapt to the changing population needs and maximise outcomes for local patients. 16 clusters have been established, covering the county in circa 30,000 population models. GCCG have invested £1.2m in transformation of primary care in 16/17, beyond the commitments required in the 5YFV and made this investment recurrent to ensure transformational change. GP provider leads have been appointed for all 7 localities in Gloucestershire. Utilise our delegated Our integrated urgent care focus has seen the commissioning development of plans and implementation of models that responsibilities to continue join up urgent care across providers i.e. community to plan and work across provision of an urgent care hub, with primary and pathways and leverage secondary care medical support provided within a MIU. these powers to support The GP Resilience Plan was developed that invited all G our members continued practices invited to apply for resilience funding. 62 resilience practices responded with plans that required funding and GCCG are currently working with NHS England and a Royal College of GP GP Ambassador to prioritise support over 16/17 & 17/18. Simplify access to urgent Work continues to improve access across primary care in primary care to avoid Gloucestershire; working with GDoc for 16/17 to provide unnecessary emergency Choice Plus appointments across the county. An Options hospital care and Develop Appraisal is currently being developed to provide ways of working to ensure integration with the OOH service. G the interface between in and out-of-hours primary care services works more effectively
Clinical Programme Approach What we said… What we have delivered… RAG Delivery of comprehensive Outcomes from pathway walkthrough and workshop transformation programme for Cardiology has seen development of action plan. through Clinical Programme Chest Pain Pathway (Trop T) initial test a completed approach, reshape end to end and roll out to commence Oct 2016. pathways of care Countywide roll out of Brain Natrurietic Peptide Testing. Tele-dermatology project undertaken, which has seen the commissioning of Dermatascopes for 54 G GP practices in Gloucestershire. 70 GPs also completed training on lesion identification and diagnosis. COPD pathway review to inform development of an integrated approach for COPD pathway redesign Provider plan development plan developed to improve performance of acute stroke care. Implementation of MSK new service model – Phase 1 complete. Implementation of Falls Strategy underway Clinical Programme Approach for Diabetes initiated for both Type 1 and Type 2 diabetes. Commissioning of new Community Eye Service. Ensure robust pathways Further development of working with our clinical compliance across the programmes to embed redesigned care pathways system, supported by G Care, across the system and focus on ensuring that all for planned and urgent care care provided is evidenced based and local policies and procedures, supported by the G-Care platform, G which disseminates pathway information to clinicians and supports improved pathway compliance and reduced clinical variation. Clinical programmes have committed to developing 3 pathways per programme by Dec 2016 Urgent Care Greater utilisation of SPCA GCCG and GCS are working collaboratively to and Peer Review with ensure optimum utlisation of the SPCA, including secondary care colleagues fortnightly meetings to assess performance against the SPCA 16/17 QIPP. This has included developing A and implementing a communications & marketing strategy, gaining stakeholder feedback on provision and the review and negotiation of key KPIs. Support providers to continue GCCG are working alongside NHSE to deliver the 4 to develop and implement key 7 day service standards, undertaking plans for 7 day services benchmarking in GHFT, and have developed a gap analysis across key providers. A MADE event is A currently being arranged to identify specific actions required to provide weekend provision. Investment in acute and community based 7 day services (system resilience investment) Ensure urgent care pathways The Urgent Care Strategy Group provide an work together in a joined up overview and leadership of urgent care pathway way; standardising approach redesign, this has included internal review of A and thresholds. pathways within GHFT and is a key part of developing our integrated Urgent Care Centres. Develop further the use of our Further work on the Directory of Services has been community hospitals. completed to ensure MIIU are profiled and ranked to maximise utilisation. GCS are currently in the process of introducing Medworx which will provide a bed base option for eligible patients. A New admission criteria for community hospital beds introduced. Plans for specialist rehabilitation services under development. Continue to undertake the Forest Health Review. Work with Urgent Emergency Integrated Urgent Care guidance has been received G Care Network to progress from NHSE. Scoping is underway as part of our Integrated Clinical Hub. Phase B procurement, which incorporates all key requirements of national agenda. Continue work to reduce A dispatch and disposition, utilisation and ambulance demand on Emergency response programme of work has been undertaken. Ambulance Services (999). The programme includes working in NHS111 to validate all Green dispositions. Looking at falls pick up service linked to fire service. GCCG is G undertaking work in care homes to reduce reliance, continuing to support roll out of community defibrillators and community first responders. GCCG has commissioned an additional HCP vehicle to convey low acuity patients to hospital. Work with Urgent Care Positive Risk Taking has been embedded as a GHFT providers to ensure the CQUIN, and the commissioned play has been principles of “positive risk shared across all key providers and viewed at major taking” are embedded across conferences. Education and training being the system to ensure patients undertaken via Schwartz rounds at GHFT and A receive care that is suitably looking at launching a campaign to support responsive to needs. centralising patient choice in all key decisions taken. GP in ED contributing to ‘Positive Risk Taking’ approach. Develop cross provider quality National Integrated Urgent Care Standards which will standards for urgent care be included in future contracting rounds. which will ensure all parts of G the urgent care pathway provide high quality care to our patients Information sharing Signed by all key providers to allow safe and arrangements between appropriate transfer of patient info. providers to encourage G coordinated and continued patient care. Planned Care Support the Clinical Major programmes of work progressed including Programme Approach in Ophthalmology and MSK programmes. providing operational and Joint working between acute and newly programme support to commissioned community urology services to reduce delivery of key clinical pressure on the acute service and progress the re- G programme groups. design of acute outpatient services. Refractory IBS Service and GP Direct Access Faecal Calprotectin Testing launched in February 2016 with promising outcomes expected following increased uptake. Deliver the Planned Care Fully established G-Care platform for disseminating work programme across the 5 pathway information supporting integrated care stages – Self pathway development. New pathways published in a A Care/Management, Access to number of key specialty areas including Services, Treatment Follow- Ophthalmology, ENT & Urology. up and Exiting Care. Programme of work to review all IFR policies completed to ensure they are reflective of up to date clinical evidence, ensure clinical support and promote policy compliance. Developed follow up programme to address demand and capacity issues within the system. This includes a number of workstreams that focus across process pathways in clinical pathways. Work continues to focus on a movement towards upper decile performance. Take an active role in Development of Elective Demand Management ensuring ongoing system Scheme to ensure pathway development and resilience for planned care. compliance across the system. Diagnostics performance against local and national targets monitored and appropriate actions worked up with providers. Including increasing capacity within the system, improving GP education and working A with Cancer leads to review current gaps in diagnostic services that need to be addressed to deliver NG12 NICE Guidelines. Review of Home Enteral Feeds Service to ensure sustainability within the system for cohort of patients and prevent re-entry to hospital.
Parity for Mental Health & Learning Disabilities What we said… What we have delivered… RAG Mental Health Deliver the Crisis Action Plan Crisis Action Plan in place, with shared goals and specifically implement a agreed across commissioners and providers. new model of Crisis Care Delivery is assessed on a quarterly basis by Steering Group. Development of new model of crisis care ongoing, including working with 2gether NHS Foundation Trust to develop a Mental Health G Acute Response Service (formally Crisis Resolution and Home Treatment Team.) Extension of Crisis Café opening hours from October 2016, funded as a 1 year pilot. Introduction of ‘Crisis House’ now planned for December. Ensure delivery of Liaison As part of the delivery of the Crisis Action Plan the Psychiatry Action Plan to Psychiatric Liaison service is now available enable delivery of shared goals 24hours a day, 7 days per week. G of the Mental Health Crisis Care Concordat Review Adult ADHD Service Mental Health Recovery service specification Specification reviewed to include Adult ADHD. Currently working to 2gether NHS Foundation trust to focus on young G people in transition and medical reviews post diagnostic assessment. Review Perinatal Mental Perinatal Mental Health Strategy and supporting Health Recovery Service action plan in place. A bid has been submitted to G Specification NHSE to request additional recurrent funding to implement a perinatal mental health service. Review the complex Work ongoing with 2gether NHS Foundation Trust psychological interventions to review the action plan for IAPT and implement action plan steps to enhance delivery across complex and R generic mental health teams. Additional investment in place. Support implementation of Joint service model under development to support changes to current self-harm young people who present in psychological or pathways social crisis. In collaboration with NHS England A work is ongoing to reduce the usage of Tier 4 beds and improve access to places of safety for young people who require intensive intervention. Improve the transition from A Quality Improvement Initiative has been children to adult services both embedded via a CQUIN across all 3 providers for A within and between providers. the last 2 years, including improving the pathway for physical and mental health conditions. Rollout a pilot of the Pilot and roll out of pathway complete and multiagency pathway for embedded across system. preschool children with G suspected Autistic Spectrum Conditions (ASC). Dementia Strengthen 2gether NHSFT Engaged with a broad range of stakeholders and post diagnostic support external consultation to complete a review of the services primary care dementia pathway; including scrutiny through process mapping on dementia services linked to the pathway. This enabled identification of G gaps and duplication, including opportunities for integration of services. A pilot with Cluster 4 in Stroud & BV has been established, looking at better integrated dementia care in a place based approach. Invest in the development of a The BME hub has been established best at the BME Community Hub, based Friendship Café and has been establishing on the existing county wide networks with other BME and support groups in Community Hubs sheltered housing units. The Intergenerational Dementia Project has used peer learning, that enabled Newent School pupils G to provide dementia awareness training to The Islamic School for Girls whose pupils are now volunteering at Friendship Café. Through the Cultural Commissioning Project, a dementia awareness raising animation using comedy has been produced. Participate in county wide Through the Intergenerational Dementia Project, a G dementia awareness competition was run for school children to produce programme in partnership with a dementia awareness raising advert; the winner of local media which was aired on Radio Gloucestershire over the summer. Lead a partnership bid for Due the progress of the Gloucestershire Archives Spirit of Achievement for the Record project, a bid was not required and investment in a county wide the project continues to make a positive impact. reminiscence network Volunteering and Befriending has been alongside the Gloucestershire successfully increased through the Connect Archives For the Record Befriending for Stroke and Dementia Service. G project, linking communities There are 12 peer support groups in place, who with libraries, museums and have made contact with 853 individuals (over 12 offering befriending and months). This includes a number of people trained volunteering opportunities to provide befriending support including 4 people living with dementia. Investment in locally developed The Active Ageing project has now established tools and resources links with all District Councils and has emerging project groups that are establishing a volunteer base and increasing activity opportunities. Following on from the 15/16 focus on using quality improvement methodology, a resource pack has been developed to support challenging behaviour, G called ‘5 Steps Approach’; aimed to successfully support patients moving from inpatient to care home. A review has been completed and considerations are being made for other areas that may benefit from the tool i.e. acute inpatients and community. LD Establish a Priority Placement Priority Placement Committee established as part Committee to keep track of all of Transforming Care Programme. future potential out of county The closure of Westridge and the consolidation of placements and to recommend inpatient beds in Hollybrook. The commissioning of G alternate arrangements two new beds with community based providers has been concluded and the renovations work has now begun. Westridge is in an active phase of decommissioning. Provide newly integrated The Learning Disability Support Service is now fully Learning Disability Intensive operational and is staffed by both health and social Support Service with care professional staff. It actively intervenes 24hrs continuing support and a day; 7 days per week to assist carers presented guidance in order to ensure its with complex and challenging behaviours and is successful embedding in instrumental within the Transforming Care current front line practice. Programme in assisting with the prevention of G unnecessary admissions to LD in-patient units. It is also a key support service to bring people back into county from in-patient units and to support the patient through potential transition related difficulties. LDISS has been cited by NHS England and the Department of health as a best practice model of care Ensure care for those with the Transforming Care Programme initiated, with most complex and challenging supporting action plan in place and submitted to needs is being delivered in the NHSE. Capital grants received from NHSE to G local community. facilitate the conversion of an existing GCC facility into a 4 flat transforming care community based support and support the Westridge closure. Ensure that the learning from Work by the Health Action group and others the health indicators for people produced a highly successful Health Action Day. with a learning disability are Well attended and GP workshops addressed the appropriately tackled and the under delivery of Annual Health Checks for people use of health care plans and with an LD. The figure remains at 48% and more health checks are increased. effort will be needed in the coming year. As part of the Quality Checking annual health checks are now A routinely scrutinised as part of the process. The LD Programme Board have made a significant commitment to attempt to correct the under delivery in the future. A patient led , expert by experience programme has been fully instituted to cover funded cases by the CCG
Integration What we said… What we have delivered… RAG Continue to deliver and refine The Rapid Response model continues to be the ICT model. available across Gloucestershire, with further work to define the model ongoing as part of the place A based approach to providing services. Clusters are continuing to design and develop the way in which ICTs are used within their 30,000 models. Continue to play a leading role The Better Care Fund for Gloucestershire was fully in the use of the Better Care approved for 2016/17. Work is ongoing with the G Fund to support greater creation of integrated commissioning hubs to integration deliver the commitments set out as part of the BCF. Implement and evaluate a Discharge to Assess model developed and ‘Discharge to Assess’ service embedded during 2016/17. Revised model under A based on best practice models development. Simplify the reablement The reablement pathway was reviewed and the pathway so that the service process simplified for acute hospital referrals. The works closely with acute and same process was adopted for community community hospitals to hospitals in June 2016 and is working well with A facilitate safe discharges home positive feedback received from Matrons. This has supported the need for system flow by prompter discharge from community hospitals. Develop stronger joint working A countywide responder service with GFRS is in with Gloucestershire Fire & place. It has been nationally recognised and forms G Rescue Service (GFRS) part of GFRS’s ‘Beyond Blue Lights’. GFRS can including rollout of a Telecare assess for basic telecare and equipment as part of Responder Service, providing their Safe & Well visits. There is ongoing Safe and Well visits and the discussion for 2017/18 for S&W visits to support development of Community hospital discharges/ proactive follow up. GFRS will Support Multidisciplinary support the Falls service as responder for non- Teams injurious falls adopting the Telecare responder service. Continue to progress the We are continuing to improve take up of telecare by telecare and various simplification of training and identification of community equipment work ‘bundles’ to support risk. Roll out of vulnerable G streams people bracelets and pre-calibrated equipment to support discharges (piloted in Community Hospitals) has taken place.
Person Centred Care What we said… What we have delivered… RAG Pilot Personal Health PHBs have been implemented in Gloucestershire on Budgets in partnership with a small scale since April 2014; there are currently 30 social care adults eligible for CHC and 2 LD patients with G personal health budgets in place. A PHB process and pathway has been developed and embedded within Gloucestershire. Be an active participant in the Gloucestershire Clinical Commissioning Group, South West Integrated Gloucestershire County Council, and a number of Personal Commissioning local voluntary and community sector organisations G Pilot. form part of the only regional demonstrator site for Integrated Personal Commissioning (IPC) in England Continue to ensure that The IPC programme in Gloucestershire sits within patient voice is a strong the Prevention and Self-Care plan as part of our influence across all of our Sustainability and Transformation Plan (STP). change programmes to Dedicated IPC steering group which will report into deliver person centred care the STP programme, and has members from health, G for all. social care and patient representatives. The IPC work programme has multiple interdependencies with other workstreams across health and social care and the steering group will ensure that work is not duplicated or carried out in an isolated manner.
System Sustainability What we said… What we have delivered… RAG Develop aligned delivery GCCG had an agreed CQUIN schedule across all of incentives its main provider contracts in 2016/17. Additionally QIPP schedules were developed with key providers that include programmes of work that aim to G generate financial savings across the system. This was supported by an agreed risk share with individual providers and an incentive driven milestone approach; delivery of which are discussed with providers in a monthly monitoring meeting. Ensure constitution compliant For 2016/17 NHS England have introduced a new services Improvement and Assessment Framework for CCGs. This framework replaces the previous CCG Assurance Framework and provides a framework based on 4 domains with 6 clinical priorities. The 6 clinical priorities are; Cancer, Dementia, Diabetes, Learning disabilities, Maternity and Mental health. Assessments are made nationally and are overseen by groups of independent experts. The baseline R results for Gloucestershire CCG were published in September 2016 (by exception): Cancer – 62 day cancer – Needs improvement Dementia – Diagnosis rate – Performing well Mental Health – IAPT recovery rate – Needs improvement Learning Disabilities – Specialist inpatient care – Needs improvement Ensure the provision of high All providers and GCCG took part in Sign Up to quality & safe services Safety campaign and GCCG was awarded a Nursing Times Award for Patient Safety Improvement for our work to raise awareness of sepsis and support frontline clinical decision making. As part of this initiative a number of tools to support clinical decision making were developed, key to which is the National Early Warning Score (NEWS) which is being adopted across our local health system to help prioritise the urgency assigned to a patients care. Quality representation embedded as part of Primary G Care Commissioning Committee. All CQC reports reviewed by Clinical Quality Review Group to offer support to GP practices that require it. Countywide HCAI Group taking forward plans to respond to NICE NG 15 and implementation of national PHE antimicrobial resistance work plan. CQUIN schedule embedded across all of our main providers in 16/17. CCG has used the CQUIN framework to develop joint CQUIN priorities across our community providers to support collaborative working and delivery of priorities across our system. Reduce avoidable variation in GCCG uses a number of resources to assess our outcomes variation in commissioning activity and outcomes across the health system such as the Dr Foster benchmarking tool. A The CCG uses benchmarking proactively as a way to of improving ourselves by learning from others. Our benchmarking approach encompasses identifying best practice and innovation to help inform areas of opportunity to improve the quality of care, performance and finances of existing services and influence service redesign. We have fully adopted the Right Care approach and customised it for Gloucestershire with local data and knowledge to cover pathways across all settings of care. Initiation of pain management programme, focusing on improving the pain pathway and a medicines optimisation approach.
Appendix 2
BUSINESS CASE
Project Name: xxx Date of Publication: dd/mm/yy
Please Note:
In line with Treasury Guidelines, any business case over £1m in value must follow the Five Case Model and therefore must not complete this business case template.
Business Cases that are deemed to have a significant political impact must follow the Five Case Model, please consult your Programme Director for confirmation of whether this is required.
Business Cases for projects with a value of less than £30k, must complete an Outline Business Case template and are not required to complete this Full Business Case template.
*Manual Table*
Table of Contents
Version Control…………………………………………………………………………………………………3 Sign off……………………………………………………………………………………………………………..3
1. STP Executive Summary………………………………………………………………………………5 2. Project/Programme Summary…………………………………………………………………….5 3. Project Team……………………………………………………………………………………………….5 4. Project Details …………………………………………………………………………………………….5 5. Strategic Fit/Outcomes and Benefits……………………………………………………………6 6. Options Appraisal…………………………………………………………………………………………7 7. Key Milestones and Deadlines……………………………………………………………………..8 8. Financial Assessment……………………………………………………………………………………8 9. Performance Monitoring………………………………………………………………………………8 10. Evaluation…………………………………………………………………………………………………….8 11. Risks…………………………………………………………………………………………………………….8 12. Delivery Impact at System and Organisational Level…………………………………….9 13. Quality and Sustainability Impact Assessment (QSIA)...………………………………..9 14. Equality Impact Assessment (EIA)...……………………………………………………………..9 15. Information Governance(IG)…………………………………………………………………………9 16. Information Technology(IT)………………………………………………………………………….9 17. Links/Dependencies ……………………………………………………………………………………10 18. Resource Requirements……………………………………………………………………………….10 19. Consultants and Procurement……………………………………………………………………..10 20. Exit Strategy…………………………………………………………………………………………………10 21. Annexes……………………………………………………………………………………………………….10 a. Stakeholder Analysis…………………………………………………………………………11 b. Communications and Engagement Plan……………………………………………12 c. Risk Analysis……………………………………………………………………………………..14
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Version Control Version No Author Date Status e.g. draft / approved
History
Version
Author:
Contributors:
Sign Off Name Date CEO Lead
Programme Director
Programme/Project Sponsor Programme/ Project Manager
Delete organisations(s) as applicable Endorsed by GCCG Organisation Board Signed…………………………………… Version number: Name…………………………………….
Date…………………………………
GHFT
Signed……………………………………
Name…………………………………….
Date…………………………………
2gtherNHSFT
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Signed……………………………………
Name…………………………………….
Date…………………………………
GCS
Signed……………………………………
Name…………………………………….
Date…………………………………
GCC
Signed……………………………………
Name…………………………………….
Date…………………………………
Endorsed by Signed…………………………………….
STP Delivery Board Name…………………………..
Version number: Date…………………………………
Endorsed by Signed……………………………………
STP Programme Board Name…………………………………….
Version number: Date…………………………………
Template Note: The Business Case Template can be utilised for a project or a programme. For this reason additional and or duplicate section titles have been included to ensure clarity between them. Therefore, please ensure it is has been identified whether your business case is being completed for a project or a programme and delete the non‐applicable titles (where these have been highlighted) as required.
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1. STP Executive Summary STP Programme Area: Choose an item. 2. Project/Programme Summary (delete as applicable) Programme Name: Which programme does this sit within?
Project Name (delete as applicable):
Nationally Invest to Invest to Project Type ( delete as appropriate) Disinvestment Other mandated save improve
If ‘other’ please describe type 3. Project Team: (delete as applicable) Role (add additional if appropriate) Name Organisation Executive Sponsor Finance Lead Information Lead Clinical Lead Programme Manager Project Manager Project Team Member 4. Project Details Explain the context of the project, what promoted its inception. Include details of any national guidance influencing the project. It may be useful to Case for Change provide a description of the current situation that this project will address. Include details of any work already carried out in relation to this project, either directly or indirectly, such as results of a bench marking exercise.
What is being proposed? Include: − Aims and objectives − Models of care and pathways Description of Project/Programme − Processes (delete as applicable) − Evidence underpinning the proposals − Resource Implications − If a programme, what projects sit within it?
Detail areas, organisations and patient groups included and those explicitly Scope excluded. How many patients are involved and what activity is associated with this proposal.
Provide a description of any constraints e.g. time limits, building, resources, Constraints other projects etc.
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5. Strategic Fit / Outcomes and Benefits What outcomes/ financial and non‐financial benefits will the proposed programme/project deliver and how will these support delivery of the ‘three gaps’ and align to the priorities set out in the Gloucestershire STP? Also consider alignment to organisational level objectives as set out in the operational plan?
• Insert here
Health & Wellbeing Gap
• Insert here Care & Quality Gap
• Insert here Finance & Efficiency Gap
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6. Options Appraisal Outline all options that have been considered (Recommend a minimum of 4 – do nothing, the minimum, the ideal solution and an alternative.)
Option 1 Option 2 Option 3 Option 4 [Option Description] [Option Description] [Option Description] [Option Description] Overview
Advantages
Disadvantages
Risks (Consider: strategic alignment, quality of care, financial, operational)
Workforce Impact
Financial Impact
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7. Key Milestones and Deadlines What is the timeline for this proposal? State key milestones and Key milestones and deadlines deadlines/start dates.
8. Financial Assessment
9. Performance Monitoring Outline the KPIs that will provide evidence of delivery of project outcomes Key Performance Indicators Detail and benefits ‐ for example, reduction in emergency admissions, ED attendances, reduction in procedures etc. 10. Evaluation Please describe the approach that has been defined for evaluating whether How will you evaluate the project? your project will be a success. For example, what information you will be collecting during the project which will show if it has been successful or not. 11. Risks
Top 3 risks and mitigation State the top three risks and mitigating actions.
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12. Delivery Impact at System and Organisational Level As a result of implementing the preferred option, how does the change impact the following? Consider quality of care, financial, operational, workforce implications.
• Insert here • Insert here Commissioner Impact
• Insert here • Insert here Provider Impact
• Insert here • Insert here System Impact
13. Quality and Sustainability Impact Assessment (QSIA)
Provide assurance to the organisation that quality and sustainability has been considered in the proposal being considered. Please complete a Quality and Sustainability Impact Assessment (found here xxx) and insert into Annex X.
14. Equality Impact Assessment (EIA)
Has an EIA been done on the proposed service change. How are quality issues improved and/or changed? Please complete a Equality Impact Assessment (found here xxx) and insert into Annex Y.
15. Information Governance (IG)
Is an information governance review required or been completed? Consult organisational policies. Consider: data sharing, information flows.
16. Information Technology (IT) Consider IT implications such as systems, fit for purrpose, data flows, technology available, licenses etc.) Ensure alignment with priorities set out in local digital road map.
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17. Links/Dependencies Does this project link to or impact other existing /proposed projects or other STP programme areas?
18. Resource Requirements Detail what existing or additional resource is required to implement the change. Quantified workforce/investment requests should be included as part of the Finance Schedule in Annex x. Consider the resource required to firstly deliver the project and then the resource needed to deliver the service change.
19. Consultants and Procurement Consultants Will external consultants be Choose an item. required? If ‘Yes’ please clearly set out the rationale for the decision to use external sources, including the alternatives considered and why 'in‐ house' resource cannot fulfil the requirement. Procurement Is procurement required? Choose an item.
If ‘Yes’ please outline the proposed procurement.
20. Exit Strategy State how the project will be closed if benefits are not realised or the scheme is not prioritised in the future.
21. Annexes Annex 1: Stakeholder Analysis Annex 2: Communication & Engagement Plan Annex 3: Risk Analysis
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Stakeholder analysis Who are the stakeholders and how have they been involved?
Stakeholder Description: Current Engagement / Awareness Planned Engagement Owner EXAMPLES: Engagement of partner organisations
Patient/Public involvement in Service Development Groups
Clinical and Staff Engagement
Engagement of Local Authorities
Briefings for Politicians
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Communication and Engagement Plan
Engagement is the active participation of the public, patients, including children and young people, carers and community representatives, in the development of health services. Engagement gives the public a say in how services are planned, commissioned (purchased/procured), delivered and reviewed. It is important to recognise who we involve through our engagement activity and we are keen to ensure that we provide opportunities for individual, group and collective engagement.
More formal engagement, for instance with the general public about proposals for a ‘substantial development’ of the health service in the area, or a ‘substantial variation’ in the provision of services, such as a changing where a service is provided from, is referred to as ‘consultation’.
What is experience?
Experience can be defined as feedback from individuals about: ‘what actually happened in the course of receiving care or treatment, both objective facts and their subjective views of it’ (Dr Foster, The Intelligent Board 2010). Although an individual may have received appropriate clinically effective interventions along a care pathway, if these have not been delivered on time or in poor clinical environments, or not communicated in a clear manner the individual may view this as a disappointing experience.
We receive experience feedback in many ways, for instance through our Experience Team (PALS and Complaints) or via providers or Healthwatch Gloucestershire, or via local and national surveys.
Please complete the table below:
Project response Engagement/Experience Activities What engagement activities are planned for the programme?
Feedback Received What feedback have you received from your engagement/experience activities?
How the feedback was used How has feedback influenced the decision making around the programme?
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Please describe what has changed as a result of the feedback received?
How will the impact be monitored? How has the impact of the decision been monitored? How has this been communicated to those who provided feedback?
What is the purpose of communication? Eg. To increase the profile of the programme and key contacts, ensure that engagement fatigue is avoided, inform key stakeholders of the impact that their feedback has made Name of consultors This can range from Organisations, Boards and Individuals
Key messages What are the key messages you need to communicate? Please ensure these are in plain English and are short/punch
Target Audiences/stakeholders Please identify those not mentioned in the stakeholder analysis
Tactics Please describe the key communication methods/tools that will be used
Timetable Include a set of key project/communication/decision making milestones and their date in bullet points below: X Y Z
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Risk analysis
A risk and issues log should be maintained for the duration of the project implementation. Risks should be considered in line with the criteria below.
Description and Type of Risk Description Financial Risk Scenario tested to give assurance of tolerance to variable outturn – how sensitive are predicted savings / costs to variance in performance? Over Performance Risk The risk that the service change will create more demand in the system.
Service Delivery Risk Can the service provide the level of activity proposed? What actions will be taken in the event of underperformance? Ensure that control measures are in place to manage underperformance Quality Risk Can the service provide the level of quality and patient outcomes that are required? Ensure that mechanisms are in place to assess service quality and performance ‐as a minimum, a service level agreement should be in place with monitoring framework
Reputation Risk How engaged have stakeholders been to date in the development of the proposal? Is there considerable local interest? Will not proceeding with the proposal present NHS Gloucester with a significant reputation risk? How can this be managed?
Other Risks Identified by proposer as relevant
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Risks are scored using the matrix below. The level of consequence is decided which gives a sum between 1 (trivial) and 5 (fatal); the probability of the risk happening is then decided which gives a sum between 1(remote) and 5 (certain). Multiplying the 2 sums together will give the risk score, e.g. consequence Major x probability Possible would be 3 x 3 = risk score 9. The risk scores are given on the matrix overleaf.
In order to decide how to handle risk, it is essential not only to identify that a certain risk exists, but also to analyse its significance. The results of the risk assessment can be graphically demonstrated in the risk matrix, reproduced below.
Green: Low; Yellow: Moderate; Amber: Significant; Red: High
Consequence 1 2 3 4 5 1 1 2 3 4 5 2 2 4 6 8 10 3 3 6 9 12 15
Likelihood 4 4 8 12 16 20 5 5 10 15 20 25
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Key: Where relevant, partner organisations support 4 Statutory Board’s for Approval 3 STP
STP Delivery Board RSG & PDG STP Delivery Board Support STP Oversight Internal CCG Support and Review 1 and Recommend Board for Info 2 Recommend 4 2 Partner
Organisations RSG & PDG Review Controlling a smallPrio rities Committee 3 Project Approve Essential Tool 3 Core Leadership Core Core Core Optional Tool Priorities STP Delivery Board STP Deelivery Board Support to proceed Leadership Leadership Leeadership Committee Support and for Info Approve 2 Support Support 2 Suppport 3 Recommend Stage 2 2 2 1 Project/Programme Project/Programme Projject/ Multi‐ STP Programme Project/Programme Project/Programme Governiing Body STP Delivery Board orgaanisational Board Recommend Board Recommend Programme Board Board Review Board Recommend Board Recommend >£1m Approve Support and for monthlly Review 1 1 1 1 d 1 4 1 Recommend 1 Where?
Option 1: Option 2: Option 3: Project or Programme/ Evaluate and Start Up Initiation Business Case Business Case value Business Case value (Incl. Trreasury Delivery Programme? Project Cllosure
When? value <£50k >£50k <£1m Rules) >£1m
What?
Mandate Programme PID Risk & Issues Log Handover and/or Project Business Case (required if committing resources) Document This may exist through Brief(s) If you are not For business cases below £50k, complete an Outline Business Case. Highlight Report Lessons Learnt strategic objectives Programme committing resources within STP/Operational you will only need a PID For business cases greater than £50k, you will also need to complete a and/or Project Change Control Risk & Issue Log Plan and can continue to the Full Business Case. Benefit’s Board ToR Delivery stage. RRealisation If Programme, please Projeccts £1m+ refer to CCG Live for Programme will be required guidance using the Work same pathway and/or Project to undertake an Team(s) ToR Package(s) annual benefits review. Benefits Map
Agenda item 12 Governing Body
Meeting Date Thursday 24th November 2016
Title Planned procurement of Social Prescribing from June 2017 onwards Executive Summary Social Prescribing has been developed by the CCG, in partnership primarily with Voluntary and Community Sector Enterprise (VCSE) organisations and local government at county and district level. Beginning with an initial phased piloting, the scheme has developed a strong model and is well supported by patients and professionals across a wide range of sectors and agencies. Introduced as a non-medical response to supporting people with wider wellbeing needs, it was designed specifically to offer one to one support and a signposting mechanism to non– clinical community based support for people with low level emotional, psychosocial and physical health needs.
From March 2016, patients in all 81 Practices across Gloucestershire have had access to a Social Prescribing service, delivered in each locality by a locality selected partner. Referrals are accepted from GP practices, Integrated Community Teams and staff in community hospitals. Patients are signposted to a number of organisations, including voluntary and community based and locally commissioned groups.
Key headlines from the findings of the external evaluation of Social Prescribing which took place during the summer of 2016 are:
a statistically significant increase in wellbeing for individuals referred to social prescribing;
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a demonstrable reduction in the use of GP time; a reduction in Emergency Department attendance and admission for individuals who engaged with social prescribing; and a predicted Return on Investment (ROI) of £1.69 (health £0.43, social £1.36) for every £1 invested by the CCG.
A part of our Enabling Active Communities Joint Action plan is a commitment to joint commissioning with Gloucestershire County Council (GCC) and in particular an action to consider joint commissioning of both Social Prescribing and what is currently the Community and Village Agent Contract, held by GCC.
Permission to proceed jointly, on this basis, was given at Joint Commissioning Partnership Executive (JCPE) at their meeting in June 2016 and by the CCG’s Core Team on 1st November. A paper will be submitted to Cabinet on the 16th November 2016.
This paper provides an update on the procurement arrangements, seeks funding approval and requests either an extraordinary Governing Body meeting or delegated authority to ratify the award decision between 30th January and 1st February 2017.
Key Issues These are explored in the report. Risk Issues: There is a risk that the procurement will not be Original Risk attractive to the market. This risk has been Residual Risk mitigated by the establishment of a Joint Procurement Team, by a Market Engagement event held on 11th October and by the ability of bidders to bid for up to two specified LOTs (LOTs 7, 8 and 9). Financial Impact £599k per annum for each of five years with a potential to extend to seven years. Legal Issues The procurement will be led by the CCG and
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(including NHS conducted under the European Union ‘Open’ Constitution) procedure. Impact on Health Yes. Equality Impact Assessment has been Inequalities completed. Impact on Equality No. Equality and Diversity Impact assessment and Diversity has been completed. Impact on Sustainable None. Development Patient and Public Yes. Patient feedback formed an integral part of Involvement the external evaluation. Patient and public involvement was undertaken as part of the development of the original business case. Recommendation The Governing Body is requested to consider:
CCG funding approval (£599k per year for up to 7 years). a request for either an extraordinary Governing Body meeting or delegated authority to ratify the award decision between 30th January and 1st February 2017. Author Helen Edwards/David Porter Designation Associate Director of Primary Care and Locality Development/Head of Procurement Sponsoring Director Ellen Rule (if not author) Director of Transformation and Service Redesign
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Agenda Item 12
Governing Body Thursday 24th November 2016 Social prescribing
1 Introduction and National and local context
1.1 Core Team members (6.9.2016) and Governing Body (29.9.2016) recently saw a film containing three case studies of people who had been supported by Social Prescribing Hub Coordinators in Forest of Dean and Tewkesbury. In addition at a Governing Body development session on 10th November, the impacts of the findings of the external evaluation of Social Prescribing were presented to members. This paper seeks to update members on planned commissioning and procurement arrangements for Social Prescribing from June 2017 onwards.
1.2 The World Health Organisation has defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease of infirmity’. A body of evidence is developing nationally that explores the value of people and communities as a positive impact on health and wellbeing. These are broken down into a family of community- centred wellbeing approaches to help provide practical, evidence based options that can be applied in local areas. Shown below:
Source: At the heart of health: realising the value of people and communities
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1.3 Enabling Active Communities is our system wide response to building a new sense of personal responsibility and improved independence for health, supporting community capacity and ensuring we make it easier for voluntary and community agencies to work in partnership with us. This approach will be used to deliver a radical Self Care and Prevention Plan led by Public Health to close the Health and Wellbeing Gap in Gloucestershire. Improving lives is a core function of the NHS, expressed in the NHS Constitution as the need for the NHS to be “helping people and their communities take responsibility for living healthier lives”. Our first year will focus on delivering Social Prescribing and the shared Prevention and Self-Care Plan. We recognise that more systematic prevention is critical in order to reduce the overall burden of disease in the population and maintain the financial sustainability of our system. Our Prevention and Self-care Programme provides a clear framework and plan for whole system change that will enable patients and communities to take a lead in their health and care. Our aim is to create the conditions for community and individuals to thrive, to remove any barriers and for our services to work to meet the needs and harness the assets of our communities in ways that are empowering, engaging and meaningful.
Source: Gloucestershire STP
2. Current commissioning arrangements
2.1 Social Prescribing has been developed by the CCG, in partnership primarily with Voluntary and Community Sector Enterprise (VCSE) organisations and local government at county and district level. Beginning with an initial phased piloting, the scheme has developed a strong model and is well supported by patients and professionals across a wide range of sectors and agencies. Introduced as a non-medical response to supporting people with wider wellbeing needs, it was designed specifically to offer one to one support and a signposting mechanism to non–clinical community based support for people with low level emotional, psychosocial and physical health needs.
2.2 From March 2016, patients in all 81 Practices across Gloucestershire have had access to a Social Prescribing service, delivered in each locality by a locality selected partner. Referrals are accepted from GP practices, Integrated Community Teams and staff in community hospitals. Patients are signposted to a number of organisations, including voluntary and community based and locally commissioned groups.
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2.3 The current service is aimed at the following patient groups:
Frequent attenders in primary care, for example those who are socially isolated or people with other psychological and emotional needs Vulnerable and at risk groups, for example low income single parents, recently bereaved older people People with long term conditions and people with mild to moderate depression and anxiety.
2.4 At the end of October 2016, in excess of 2,800 people had been referred to the programme.
2.5 The CCG has a recurrent budget of £599k to deliver social prescribing. A spend of £505K is predicted in 2016/17.
3. Findings from the external evaluation of Social Prescribing
3.1 An external evaluation undertaken over the summer of 2016 by the University of the West of England (UWE) demonstrated key beneficial impacts.
3.2 The primary outcome measure was improvement in patient wellbeing. There was a statistically significant increase in reported short WEMWBS scores from baseline. The mean increase in mental health scores was 3.83 with a 95% confidence level.
3.3 Scrutiny of the data suggests that those patients who were referred to social prescribing had lower emergency admissions rates after six months than those patients who refused the service or were uncontactable. There is a 23% decline in A and E admissions in the six months after compared to the six months before. Not only is it lower but it is contrary to an increase in emergency admissions in patients who refused to engage with the social prescribing service.
3.4 Looking at primary care data there is a clear reduction in the number of patient encounters with GP services. Of the patient records of 1,147 different patients who have been referred to the social prescribing service, GP appointments declined by 21% in the six months after referral to a social prescribing co-ordinator compared to six months before. The number of GP home visits declined by 26% and the number of GP telephone calls by 6%.
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3.5 Adding 12 months savings to the health service with the estimated (social) savings it is believed that in the first year there is a £1.69 (health £0.43, social £1.26) return on investment for every £1 spent by GCCG on the social prescribing service. This return on investment is probably an under estimation because the social prescribing service are yet to develop a rigorous and consistent way of counting impact across the six hubs.
4. Future commissioning arrangements
4.1 A component of our Enabling Active Communities Joint Action plan is a commitment to joint commissioning with a particular action to consider joint commissioning of both Social Prescribing and what is currently the Community and Village Agent Contract, held by GCC. Permission to proceed jointly, on this basis, was given at Joint Commissioning Partnership Executive (JCPE) at their meeting in June 2016 and by the CCG’s Core Team on 1st November. A decision from Cabinet is expected on 16th November.
4.2 35 Village and Community agents work across the county. The key objectives of this scheme have been:
to help older people in the most rurally isolated parts of Gloucestershire feel more independent, secure, cared for and have a better quality of life; to give older people easy access to a wide range of information that will enable them to make informed choices about their present and future needs; to help older people access services or assistance that can help them to remain independent and in their own homes as well as part of a supportive enabling community; and to engage older people to enable them to influence future service planning and provision.
4.3 This scheme is open to self-referrals with referrals accepted if a person is aged 50 plus years. This scheme has been funded by GCC (Adult Social Care and Public Health). The funding for this service will change from 1st June 2017.
4.4 A new service specification which amalgamates the current Social Prescribing programme, the Community and Village Agent service and GCC’s commissioning of a project entitled “Intouch” has been jointly
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written and a procurement team established.
4.5 An initial market engagement event took place on 11th October. This was attended by 67 people from 18 large organisations, 28 small organisations and 2 statutory organisations. Providers were asked for their preference for six, three or two lots. A clear preference for six lots was given.
5. Procurement
5.1 A project team responsible for over-seeing the procurement process has been established with representative from both GCCG and GCC. As GCCG will contribute the majority of the annually agreed funding, GCCG’s procurement staff will lead the procurement process but will work collaboratively with GCC commercial staff to ensure that the council’s specification requirements (specifically associated with Village Agents and Intouch) are included.
5.2 Indicative Procurement timetable
Stage: Date(s): Notes:
GCC Cabinet 16 November . Approval to commit Meeting 2016 funding
CCG Governing 24 November . Approval to commit
Body 2016 funding
. Background paper and
seek approval for
delegated authority to
award contract in
January / February
2017
Publish Contract 25 November . EU Open Procedure
Opportunity 2016 . Advertisement period
Advertisements: 35 days minimum (or 30
days for electronic
. Official Journal receipt of tenders).
of the Assuming use of Pro-
European Contract e-tendering Page 8 of 12
Union (Light system. Touch . Include Provider Regime) Assessment . Contracts Questionnaire (PAQ) in Finder ITT (GCCG) . Invitation to Tender . Pro-Contract document available (GCC) from day of publication
Advertisements 6 January closing date 2017
Deadline for receipt Noon, 13 . Electronic receipt by of ITT offer January 2017 GCC submissions
ITT evaluation 16 January . Where bidder process (to include): 2017 to 27 presentations are January 2017 required they will be . Clarification scored / weighted and requests (where this will be reflected in required) the overall scoring . Bidder methodology as shown presentations in the Invitation to (where required / Tender documents to be determined) . Scoring moderation meeting
Prepare / submit 30 January . Submit to Accountable contract award 2017 Officer for approval via recommendation delegated authority OR paper to extraordinary Governing Body meeting
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Inform preferred 1 February bidder(s) and 2017 unsuccessful bidder(s)
Observe mandatory 1 February . Minimum of 10 calendar standstill period 2017 to 11 days February 2017
Formal contract From 12 . Advise successful award February bidder(s) 2017 . Populate NHS standard contract schedules . Agree bidder debriefs where required
Contract From . TUPE transfers (where mobilisation / February applicable) implementation 2017
Publish contract Within 30 . Contracts Finder / OJEU / award notice days of ProContract contract award
Contract 2 June 2017 commencement
5.3 Contract Duration
Gloucestershire County Council and NHS Gloucestershire Commissioners both seek contract duration of an initial period of 5-years with an option to extend for a further period of 2-years. Longer contracts will enable successful providers to fully embed, and subsequently develop their service proposals and to establish positive lateral working relationships
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with other service LOT providers for the benefit of overall contract management. The longer contract period also affords staff responsible for delivery of the service improved employment security.
5.4 Division into LOT’s
5.4.1 It is anticipated that Community Connectors will be advertised as a contract opportunity sub-divided into 9 LOTs by the following localities:
1. Gloucester 2. Tewkesbury 3. Forest of Dean 4. Cheltenham 5. Stroud 6. The Cotswolds 7. Gloucester and Forest of Dean 8. Cheltenham and Tewkesbury 9. Stroud and Cotswold
5.4.2 Bidding organisations will have the opportunity to bid for one or more LOTs (from LOTs 1 to 6) but will only be awarded a maximum of one of these LOTs. This approach complies with Regulation 46 of the European Union Public Contracts Regulations 2015 which actively encourages contracting authorities to improve access for Small and Medium Enterprises (SME’s). Consequently a minimum of 3 or a maximum of 6 individual contracts will be awarded.
5.4.3 There is a risk that some LOTs may not attract a viable bidder, particularly in the case of smaller LOTs such as Tewkesbury. However, this has been mitigated by permitting providers to bid for one specified LOT (LOTs 7, 8 and 9) and by the feedback from the Market Engagement event at which providers expressed a clear preference for a number of smaller LOTs.
5.5 Contract Award Recommendation Process
5.5.1 A contract award recommendation paper will be drafted by 30 January in- line with the indicative procurement timetable. Governing Body approval to award is required and either an extraordinary Governing Body meeting or delegated authority is sought to ratify the award decision between 30 January and 1 February 2017.
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6 Recommendations
6.1 CCG funding approval requested (£599k per year for up to 7 years).
6.2 Either an extraordinary Governing Body meeting or delegated authority is sought to ratify the award decision between 30 January and 1 February 2017.
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Agenda item 13 Governing Body
Meeting Date Thursday 24th November 2016 Title Out of Hours (OOH) Procurement Update Executive Summary GCCG is undertaking a procurement to secure a short-term contract required for the provision of OOH primary care services from 1 June 2017 to 31 March 2018 (10-months). (Project A). This contract will allow time for a re-procurement of an integrated OOH / NHS111/ Clinical Hub service from 1 April 2018 (Project B) This paper provides timescales and an update on both procurements. Key Issues No issues have been raised
Risk Issues: All project risks are logged and mitigations Original Risk identified where possible Residual Risk Financial Impact Running two procurement processes simultaneously will incur some further charges, e.g. provision of legal advice. The financial envelope for Project A has been agreed. The financial envelope for Project B will be set once the scope of the procurement has been finalised Legal Issues (including Legal advice was previously sought ahead of NHS Constitution) the decision to procurement an interim 10 month contract. Impact on Health None Inequalities Impact on Equality and None Diversity Impact on Sustainable None Development Patient and Public Not required at this stage (service model does Involvement not change under this process). Recommendation The Governing Body is requested to note the
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progress made on Project A and timeline for Project B OOH NHS 111 procurement. Author Gill Bridgland Commissioning Implementation Manager David Porter Head of Procurement Sponsoring Director Mark Walkingshaw (if not author) Deputy Accountable Officer
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Agenda Item 13
Governing Body 24th November 2016 Primary Care OOH Procurement Update
1 Introduction
1.1 Earlier this year, South Western Ambulance Service NHS Foundation Trust (SWASFT) gave 12 months’ notice of its intention to cease provision of Primary Care Out of Hours (OHH) services in Gloucestershire from 31 May 2017.
1.2 GCCG has explored the options available to ensure continuity of the OOH service for the Gloucestershire population and sought legal advice to ensure compliance with procurement and employment law.
1.3 GCCG agreed to seek a short term 10 month contract to ensure that the OOH contract end date is co-terminus with the end of the existing Care UK NHS 111 contract (31st March 2018). This would enable GCCG to consolidate both service requirements into a new integrated model and single contractual arrangement from April 2018. This was also designed to take account of the changes required to the county’s urgent care system as part of the Sustainability and Transformation Plan.
1.4 GCCG agreed to seek to secure a new short term OOH service provider for a period of 10 months, from 1 June 2017 to 31 March 2018 (Project A). Procurement legislation requires the CCG to go through a formal tender process as there is a range of out of hours service providers qualified and able to deliver this service.
1.5 A new 3 to 5 year contract will be sought to start from 1 April 2018 (Project B). This will offer the CCG an opportunity to consider what is needed from the service over the longer term, alongside our work on reviewing the urgent care system in Gloucestershire. The aim of this will be to ensure truly joined up urgent and emergency care services for the people of Gloucestershire.
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2 Procurement Update (Project A)
2.1 An advertisement for initial expressions of interest from healthcare service providers to run the county’s out of hours primary care service from 1 June 2017 was placed on 3 October 2016. Five expressions of interest were received and all potential bidders passed the Standard Qualification Questionnaire (SQQ).
2.2 The deadline for formal bids is 25th November 2016 and bids will be evaluated between receipt and 23rd December 2016. A Bidder Presentation Day will take place on 21st December. The contract will be awarded to the preferred bidder in January 2017.
2.3 Offer submissions will be evaluated in accordance with the evaluation criteria previously published in the Invitation to Tender document. Evaluation weightings have been split, 30% for overall financial offer and 70% for service quality and delivery (including service mobilisation).
2.4 A comprehensive evaluation panel has been agreed and comprises senior staff from quality, commissioning, finance / information, governance, HR, IM&T and procurement disciplines. The evaluation process is scheduled to include bidder presentations plus a scoring moderation stage to confirm the veracity of individual evaluator scores and associated comments.
2.5 Thereafter, there will be a period of mobilisation before SWASFT hands over the contract to the new provider at the end of May 2017. We know that SWASFT is committed to providing a quality service for patients over the course of the next eight months as well as working in partnership to ensure a smooth transition to a new provider.
3 Procurement Update (Project B)
3.1 A separate procurement process will be undertaken for this contract which will include Primary Care OOH and NHS 111 services and an Integrated Clinical Hub as a minimum. Further work is required to agree the full specification and financial envelope. The procurement project team is working closely with the ‘Development of Integrated Primary and Community Based/led Urgent Care Project’ to ensure a joined up approach and a specification which will reflect the outputs
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and recommendations of the work they have already undertaken.
4 Recommendation 4.1 The Governing Body is requested to note the progress made on Project A and timeline for Project B OOH NHS 111 procurement.
5 Appendices
. Appendix 1 – Procurement Timetables
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Appendix 1
High Level Procurement Timetable Project A and Project B
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 16 16 16 17 17 17 17 17 17 17 17 17 17 17 17 18 18 18 18 18
Advert placed 3/10/16
Deadline for receipt of PQQ submissions 21/10/16
PQQ evaluation 21/10/16 – 28/10/16
Dispatch ITT documents to shortlisted bidders 31/10/16
Project A Deadline for receipt of ITT submissions 25/11/16
ITT Evaluation process 25/11/16 – 23/12/16
Extraordinary GCCG Governing Body Meeting 12/01/17
Formal Contract Award 24/01/17
Mobilisation / Contract Implementation Contract Start Date 01/06/17 Development of the specification in line with the Glos Urgent Care Strategy
Engagement events – 02/12/16 & 14/12/16
Advert placed 09/01/17
B Deadline for receipt of PQQ submissions 17/02/17
PQQ evaluation 17/02/17 - 03/03/17
Dispatch ITT documents to shortlisted bidders 06/03/17
Project ITT Evaluation process 02/05/17 – 02/06/17
Extraordinary GCCG Governing Body Meeting 22/06/17
Formal Contract Award 04/07/17
Mobilisation / Contract Implementation Contract Start Date 01/04/18
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Agenda Item 14
Governing Body
Governing Body Meeting Thursday 24th November 2016 Date Title Revision of the GCCG Constitution
Executive Summary The Constitution was last reviewed by the Governing Body in January 2015 and the proposed changes were subsequently approved by NHS England on the 6th February 2015. The revision was necessary to reflect the responsibilities delegated to the CCG in relation to primary care commissioning.
The document has again been reviewed to ensure that it remains relevant and suitable for the organisation. In accordance with advice received from NHS England to reduce the size of the Constitution, a number of documents that were previously appended have now been extracted and collected into a supporting documents volume. The ‘Supporting Documents to the Constitution’ will be referred to in, but not part of, the Constitution and, like the Constitution, will be available on the CCG website.
Following review by the Governing Body, any changes to the Constitution need to be ratified by member practices before the formal approval of NHS England is sought. Changes to the supporting documents will be able to be made by the Governing Body.
Key Issues The principal proposed changes made to the Constitution are the removal of the following appendices, which are now contained in the
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separate volume ‘Supporting Documents to the Constitution’: Detailed Scheme of Delegation; Prime Financial Policies; Committee Terms of Reference; and Locality Executive Group Terms of Reference.
In addition, a number of changes have been proposed to clarify the document in certain areas. These principally include: the processes for the appointment of the Clinical Chair and the Deputy Clinical Chair; and the standards of business conduct processes, to reflect the recently issued national guidance.
The opportunity has also been taken to suggest revisions to the Committee Terms of Reference, now contained within the ‘Supporting Documents’.
All changes made, other than minor typographical corrections, are shown by way of ‘tracked changes’ in both documents.
Risk Issues: The absence of a fit for purpose Constitution could result in inappropriate actions being taken that may not comply with legislation, national guidance or good practice.
Original Risk (1x3) = 3 Residual Risk (0x3) = 0 Financial Impact None Legal Issues (including Not Applicable. NHS Constitution) Impact on Equality and Not Applicable. Diversity
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Impact on Health There are no direct health and equality Inequalities implications contained within this document.
Impact on Sustainable There are no direct sustainability implications Development contained within this document. Patient and Public Not applicable. Involvement Recommendation The Governing Body is requested to:
a) approve the proposed changes to the Constitution; b) recommend ratification of the Constitution changes by member practices and subsequent formal approval by NHS England; and c) approve the ‘Supporting Documents to the Constitution’.
Author and Designation Alan Potter, Associate Director of Corporate Governance Sponsoring Director Mary Hutton (if not author) Accountable Officer
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Agenda Item 14
Governing Body
Thursday 24th November 2016
Revision of the GCCG Constitution
1. Introduction
1.1 The Constitution establishes the principles and values of the Clinical Commission Group (CCG) in commissioning care for the Gloucestershire health community.
1.2 The Constitution sets out the arrangements the CCG has made to discharge its functions, the role of its Governing Body and its key processes for decision making, including arrangements for securing transparency in the decision making processes.
1.3 The Constitution was last reviewed by the Governing Body in January 2015 and the proposed changes were subsequently approved by NHS England on the 6th February 2015. The revision was necessary to reflect the responsibilities delegated to the CCG in relation to primary care commissioning.
2. Changes proposed
2.1 The document has again been reviewed to ensure that it remains relevant and suitable for the organisation. The proposed revision is attached at Appendix 1. In accordance with advice received from NHS England to reduce the size of the Constitution, a number of documents that were previously appended have now been extracted and collected into a supporting documents volume. The ‘Supporting Documents to the Constitution’, shown at Appendix 2, will be
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referred to in, but not part of, the Constitution and, like the Constitution, will be available on the CCG website.
2.2 The principal proposed changes made to the Constitution are the removal of the following appendices, which are now contained in the separate volume ‘Supporting Documents to the Constitution’:
Detailed Scheme of Delegation; Prime Financial Policies; Audit Committee Terms of Reference; Remuneration Committee Terms of Reference; Integrated Governance and Quality Committee Terms of Reference; Priorities Committee Terms of Reference; Primary Care Commissioning Committee Terms of Reference; and Locality Executive Group Terms of Reference.
2.3 In addition, a number of changes have been proposed to clarify the document in certain areas. These principally include:
the processes for the appointment of the Clinical Chair and the deputy Clinical Chair; and the standards of business conduct processes, to reflect the recently issued national guidance.
2.4 The opportunity has also been taken to suggest revisions to the Committee Terms of Reference, now contained within the ‘Supporting Documents’.
2.5 All alterations, other than minor typographical corrections, are shown on the attached documents by way of ‘tracked changes’.
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3. Constitution change process
3.1 In accordance with the ‘Procedures for clinical commissioning group constitution change, merger or dissolution’ issued by NHS England on the 3rd November 2016, any changes to the Constitution should be discussed and agreed with member practices before approval for the changes is sought from NHS England.
4. Recommendations
The Governing Body is requested to: a) approve the proposed changes to the Constitution; b) recommend ratification of the Constitution changes by member practices and subsequent formal approval by NHS England; and c) approve the ‘Supporting Documents to the Constitution’.
5. Appendices
1. Constitution 2. Supporting Documents to the Constitution
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Appendix 1
Gloucestershire Clinical Commissioning Group
Constitution
Version 11 (September 2016)
CONTENTS
Part Description Page Foreword 4 1 Introduction and Commencement 5 1.1 Name 5 1.2 Statutory Framework 5 1.3 Status of this Constitution 4 1.4 Amendment and variation of this Constitution 6 2 Area Covered 7 3 Membership 8 3.1 Membership of the Clinical Commissioning Group 8 3.2 Eligibility 12 4 Mission, Values and Aims 13 4.1 Mission 13 4.2 Values and Aims 13 4.3 Principles of good governance 13 4.4 Accountability 15 5 Functions and General Duties 16 5.1 Functions 16 5.2 General duties 17 5.3 Joint commissioning arrangements with other Clinical 21 Commissioning Groups 5.4 Joint commissioning arrangements with NHS England for the 22 exercise of CCG functions 5.5 Joint commissioning arrangements with NHS England for the 23 exercise of NHS England’s functions 5.6 General financial duties 25 5.7 Other relevant regulations, directions and documents 26 6 Decision Making: The Governing Structure 27 6.1 Authority to act 27 6.2 Scheme of reservation and delegation 27 6.3 General 27 6.4 Committees of the Group 28 6.5 Joint arrangements 28 6.6 The Governing Body 29 7 Roles and Responsibilities 34 7.1 Gloucestershire Clinical Commissioning Group 34 7.2 Gloucestershire Clinical Commissioning Group Role 34 7.3 Locality Executive Groups 34 7.4 Communications Approach 35 7.5 Role of GP/OHP Clinical Commissioning Leads 36 7.6 Practice Representatives 37 Gloucestershire Clinical Commissioning Group’s Constitution - 1 - Version: 11. Date: September 2016
Part Description Page 7.7 Memorandum of Agreement 38 7.8 Other Key Roles 38 7.9 All members of the Group’s Governing Body 39 7.10 The Clinical Chair of the Governing Body 39 7.11 The Deputy Clinical Chair of the Governing Body 40 7.12 Role of the Accountable Officer 40 7.13 Role of the Chief Finance Officer 41 7.14 Role of Lay Members 41 7.15 Role of the Registered Nurse 42 7.16 Role of the Secondary Care Specialist 43 7.17 Joint Appointments with other organisations 43 8 Standards of Business Conduct and Managing Conflicts of Interest 44 8.1 Standards of business conduct 44 8.2 Conflicts of interest 44 8.3 Declaring and registering interests 45 8.4 Managing conflicts of interest: general 46 8.5 Managing conflicts of interest: contractors and people who provide 48 services to the Group 8.6 Transparency in procuring services 49 9 GCCG as an employer 50 10 Transparency, Ways of Working and Standing Orders 51 10.1 General 51 10.2 Standing Orders 51
Appendix Description Page A Definitions of Key Descriptions used in this Constitution 52 B List of Member Practices 54 C Standing Orders 55 D Scheme of Reservation and Delegation 71 E Detailed Scheme of Delegation 87 F Prime Financial Policies 124 GE The Nolan Principles 136 HF The Seven Key Principles of the NHS Constitution 137 I Checklist for a Clinical Commissioning Group’s Constitution 139 JG CCG Governance Structure 141 K Terms of Reference Audit Committee 142 L Terms of Reference Remuneration Committee 148 M Terms of Reference Integrated Governance and Quality Committee 151 N Terms of Reference Priorities Committee 157 O Terms of Reference Primary Care Commissioning Committee 160 P Terms of Reference Locality Executive Group 166 Gloucestershire Clinical Commissioning Group’s Constitution - 2 - Version: 11. Date: September 2016
Part Description Page QH Memorandum of Understanding 169
Gloucestershire Clinical Commissioning Group’s Constitution - 3 - Version: 11. Date: September 2016
FOREWORD
Gloucestershire Clinical Commissioning Group (GCCG) will embedhas embedded clinical leadership at the heart of commissioning in Gloucestershire, supporting transformation to the new model of Clinical Commissioning set out in the Health and Social Care Act 2012. Our approach is set out in our vision, values and mission statement:
Our Vision:
Joined up care for the people of Gloucestershire.
Values/Aims:
We will: . ensure effective communication and engagement with patients, carers, community partners, the public and clinicians; . use our clinical experience to ensure high quality, safe and efficient services for the people of Gloucestershire; . focus on clinical benefit and health outcomes – making best use of the money and resources available; . use our clinical experience to lead innovation and change – right care, right place, right time; and . be accountable and transparent in our decision making.
Mission Statement
. To commission excellent and modern health services on behalf of the NHS for all people in Gloucestershire through effective clinical leadership, with particular focus on patient safety and continuous improvements in the patient experience.
This Constitution establishes the principles and values of GCCG in commissioning care for the health community of Gloucestershire.
It also describes the governing principles, rules and procedures that GCCG will establish to ensure probity and accountability in the day to day running of GCCG, to ensure decisions are taken in an open and transparent way and that the interests of patients and the public remain central to the values/aims of GCCG.
This Constitution applies to all member practices, GCCG employees, individuals working on behalf of the Group including anyone who is a member of the Group’s Governing Body (including members of the Governing Body’s Committees) and any other employee or other person working on behalf of the Group.
This Constitution will be reviewed in March 2016 2018 and updated as necessary to reflect the transfer of responsibility, and thereafter at least every 3 years with the involvement of clinicians, the public, patients, carers, community partners and staff.
Gloucestershire Clinical Commissioning Group’s Constitution - 4 - Version: 11. Date: September 2016
1. INTRODUCTION AND COMMENCEMENT
1.1. Name
1.1.1. The name of this clinical commissioning group is Gloucestershire Clinical Commissioning Group (“GCCG”, “the Group”).
1.2. Statutory Framework
1.2.1. Clinical commissioning groups are established under the Health and Social Care Act 2012 (“the 2012 Act”).1 They are statutory bodies which have the function of commissioning services for the purposes of the health service in England and are treated as NHS bodies for the purposes of the National Health Service Act 2006 (“the 2006 Act”).2 The duties of clinical commissioning groups to commission certain health services are set out in section 3 of the 2006 Act, as amended by section 13 and 14 of the 2012 Act, and the regulations made under that provision.3
1.2.2. The NHS Commissioning Board (hereafter referred to as NHS England) is responsible for determining applications from prospective groups to be established as clinical commissioning groups4 and undertakes an annual assessment of each established group.5 It has powers to intervene in a clinical commissioning group where it is satisfied that a group is failing, or has failed, to discharge any of its functions or that there is a significant risk that it will fail to do so.6
1.2.3. Clinical commissioning groups are clinically-led membership organisations with constituent members. The members of the Clinical Commissioning Group are responsible for determining the governing arrangements for their organisations, which they are required to set out in a constitution.7
1.3. Status of this Constitution
1.3.1. This Constitution is made between the members of Gloucestershire Clinical Commissioning Group and has effect from 1st April 2013, when NHS England established the Group.8 The Constitution will be published on the Group’s dedicated website, and will also be available on request from GCCG.
1.3.2. Documentation will be available upon request for inspection at:
1 See section 1I of the 2006 Act, inserted by section 10 of the 2012 Act 2 See section 275 of the 2006 Act, as amended by paragraph 140(2)(c) of Schedule 4 of the 2012 Act 3 Duties of clinical commissioning groups to commission certain health services are set out in section 3 of the 2006 Act, as amended by section 13 of the 2012 Act 4 See section 14C of the 2006 Act, inserted by section 25 of the 2012 Act 5 See section 14Z16 of the 2006 Act, inserted by section 26 of the 2012 Act 6 See sections 14Z21 and 14Z22 of the 2006 Act, inserted by section 26 of the 2012 Act 7 See in particular sections 14L, 14M, 14N and 14O of the 2006 Act, inserted by section 25 of the 2012 Act and Part 1 of Schedule 1A to the 2006 Act, inserted by Schedule 2 to the 2012 Act and any regulations issued 8 See section 14D of the 2006 Act, inserted by section 25 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 5 - Version: 11. Date: September 2016
Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucestershire GL3 4FE
1.4. Amendment and Variation of this Constitution
1.4.1. This Constitution can only be varied in two circumstances:9
a) where the Group applies to NHS England and that application is granted; or
b) where, in the circumstances set out in legislation, NHS England varies the Group’s Constitution other than on application by the Group.
9 See sections 14E and 14F of the 2006 Act, inserted by section 25 of the 2012 Act and any regulations issued Gloucestershire Clinical Commissioning Group’s Constitution - 6 - Version: 11. Date: September 2016
2. AREA COVERED
2.1. The geographical area covered by Gloucestershire Clinical Commissioning Group is coterminous with that covered by Gloucestershire County Council, covering 271,207 hectares with a population of 616,340approximately 620,000 which is divided into the following district councils:
. Cheltenham Borough Council; . Cotswold District Council; . Forest of Dean District Council; . Gloucester City Council; . Stroud District Council; and . Tewkesbury Borough Council.
2.2 All constituent practices are located within the same local authority boundary.
Gloucestershire Clinical Commissioning Group’s Constitution - 7 - Version: 11. Date: September 2016
3. MEMBERSHIP
3.1. GP Practice Membership of Gloucestershire Clinical Commissioning Group
3.1.1. The following practices comprise the members of Gloucestershire Clinical Commissioning Group.
Practice Name Address (Main Surgery Only)
Cheltenham Locality Berkeley Place Surgery 11 High Street, Cheltenham, Gloucestershire
Corinthian Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Crescent Bakery Surgery Crescent Bakery, St Georges Place, Cheltenham Leckhampton Surgery Lloyd Davies House, 17 Moorend Park Road, Cheltenham Overton Park Surgery Overton Park Road, Cheltenham, Gloucestershire Portland Practice St Paul's Medical Centre, 121 Swindon Road, Cheltenham Royal Crescent Surgery 11 Royal Crescent, Cheltenham, Gloucestershire Royal Well Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Seven Posts Surgery Prestbury Road, Cheltenham, Gloucestershire
Sixways Clinic London Road, Charlton Kings, Cheltenham
Springbank Surgery Springbank Way, Cheltenham, Gloucestershire
St Catherine's Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham St George's Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Stoke Road Surgery 4 Stoke Road, Bishops Cleeve, Cheltenham
Underwood Surgery 139 St George's Road, Cheltenham, Gloucestershire Winchcombe Medical Centre Greet Road, Winchcombe, Cheltenham
Yorkleigh Surgery 93 St George's Road, Cheltenham, Gloucestershire Forest of Dean Locality Blakeney Surgery Mill End, Blakeney, Gloucestershire
Brunston and Lydbrook Cinderhill, Coleford, Gloucestershire Practice
Gloucestershire Clinical Commissioning Group’s Constitution - 8 - Version: 11. Date: September 2016
Practice Name Address (Main Surgery Only)
Coleford Health CentreFamily Railway Drive, Coleford, Gloucestershire Doctors
Dockham Road Surgery Dockham Road Surgery, Cinderford, Gloucestershire Drs Andrew, Edwards, Hayes & Yorkley Health Centre, Bailey Hill, Yorkley, ClearyYorkley and Bream Lydney Practice
Drybrook Surgery Drybrook, Gloucestershire
Forest Health Care The Health Centre, Dockham Road, Cinderford
Lydney Practice The Health Centre, Albert Street, Lydney
Mitcheldean Surgery Brook Street, Mitcheldean, Gloucestershire
Newnham Surgery High Street, Newnham on Severn, Gloucestershire Severnbank Surgery Tutnalls Street, Lydney, Gloucestershire
Gloucester City Locality Barnwood Medical Practice 51 BarnwoodAspen Centre, Horton Road, Gloucester, Gloucestershire Bartongate Surgery 115 Barton Street, Gloucester, Gloucestershire
Cheltenham Road Surgery 16 Cheltenham Road, Gloucester, Gloucestershire College Yard Surgery Mount Street, Westgate, Gloucester Gloucester City Health Centre The Park, Gloucester, Gloucestershire
Gloucester Health Access Eastgate House, 121-131 Eastgate Street, Centre Gloucester Hadwen Medical Practice Glevum Way Surgery, Abbeydale, Gloucester
Heathville Medical Practice 5 HeathvilleAspen Centre, Horton Road, Gloucester, Gloucestershire Hucclecote Surgery 5A Brookfield Road, Hucclecote, Gloucestershire Kingsholm Surgery Alvin Street, Gloucester, Gloucestershire
London Road Medical Practice 97 LondonAspen Centre, Horton Road, Gloucester, Gloucestershire Longlevens Surgery 19b Church Road, Longlevens, Gloucester
Partners in Health Pavilion Family Doctors, 153a Stroud Road,
Gloucestershire Clinical Commissioning Group’s Constitution - 9 - Version: 11. Date: September 2016
Practice Name Address (Main Surgery Only)
Gloucester Quedgeley Medical Centre Olympus Park, Quedgeley, Gloucester
Rosebank Health 153b Stroud Road, Gloucester, Gloucestershire Saintbridge Surgery Askwith Road, Saintbridge, Gloucestershire
St. Johns AvenueChurchdown 24 St John’s Avenue, Churchdown, Surgery Gloucester, Gloucestershire
The Brockworth Surgery Abbotswood Road, Brockworth, Gloucestershire North Cotswolds Locality Chipping Campden Surgery Back Ends, Chipping Campden, Glos
Cotswold Medical Practice Moore Road, Bourton on the Water, Cheltenham Mann Cottage Surgery Stow Road, Moreton in Marsh, Cheltenham
Stow Surgery Well Lane, Stow on the Wold, Gloucestershire
White House Surgery Stow Road, Moreton in Marsh, Gloucestershire
South Cotswolds Locality The Avenue Surgery 1 The Avenue, Cirencester, Gloucestershire
Hilary Cottage Surgery Keble Lawns, Fairford, Gloucestershire
Lechlade Medical Centre Oak Street, Lechlade, Gloucestershire
The Park Surgery Old Tetbury Road, Cirencester, Gloucestershire Phoenix Surgery 9 Chesterton Lane, Cirencester, Gloucestershire Rendcomb Surgery Rendcomb, Cirencester, Gloucestershire
Romney House 41-43 Long Street, Tetbury, Gloucestershire
St Peter's Road Surgery 1 St Peter's Road, Cirencester, Gloucestershire Stroud Locality Acorn Practice May Lane Surgery, Dursley, Gloucestershire
Beeches Green Surgery Beeches Green, Stroud, Gloucestershire
Cam and Uley SurgeryFamily 42 The Street, Uley, Dursley, Gloucestershire Practice
Gloucestershire Clinical Commissioning Group’s Constitution - 10 - Version: 11. Date: September 2016
Practice Name Address (Main Surgery Only)
Chipping Surgery Symn Lane, Wotton under Edge, Gloucestershire Culverhay Surgery Wotton under Edge, Gloucestershire
Frampton Surgery Whitminster Lane Frampton on Severn, Gloucestershire Frithwood Surgery 45 Tanglewood Way, Bussage, Stroud
High Street Medical Centre 31 High Street, Stonehouse, Gloucestershire
Hoyland HousePainswick Gyde Road, Painswick, Gloucestershire Surgery
Locking Hill Surgery Locking Hill, Stroud, Gloucestershire
Marybrook Medical Centre Marybrook Street, Berkeley, Gloucestershire
Minchinhampton Surgery Bell Lane, Minchinhampton, Gloucestershire
Prices Mill Surgery New Market Road, Nailsworth, Gloucestershire
Regent Street Surgery 73 Regent Street, Stonehouse, Gloucestershire Rowcroft Medical Centre Stroud, Gloucestershire
St Lukes Medical Centre 53 Cainscross Road, Stroud, Gloucestershire
Stonehouse Health Clinic High Street, Stonehouse, Gloucestershire
Stroud Valleys Family Practice Beeches Green Health Centre, Stroud, (Staniforth) Gloucestershire Walnut Tree Practice May Lane Surgery, Dursley, Gloucestershire
Tewkesbury Locality Church Street Practice 77 Church Street, Tewkesbury, Gloucestershire Newent Family Practice (Holts Watery Lane, Newent, Gloucestershire Health Centre)
Jesmond House Practice Chance Street, Tewkesbury, Gloucestershire
Watledge Surgery Barton Road, Tewkesbury, Gloucestershire Mythe Medical Practice Barton Road, Tewkesbury, Gloucestershire The Staunton and Corse Corse, Staunton, Gloucester Surgery
Gloucestershire Clinical Commissioning Group’s Constitution - 11 - Version: 11. Date: September 2016
3.1.2. Appendix B of this Constitution contains the list of member practices, together with the signatures of the practices’ representatives confirming their agreement to this Constitution.
3.2. Eligibility
3.2.1. Providers of primary medical services to a registered list of patients under a General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS) contract will be eligible to apply for membership of this Group10.
No GP practice shall become a member of GCCG unless that practice:
(a) is a holder of a primary medical contract;
(b) is a primary care services provider in the relevant Locality;
(c) has completed an application for membership to GCCG;
(d) has submitted an application to NHS England and had its application approved; and
(e) has been entered into the Register of Members.
10 See section 14A(4) of the 2006 Act, inserted by section 25 of the 2012. Regulations to be made Gloucestershire Clinical Commissioning Group’s Constitution - 12 - Version: 11. Date: September 2016
4. MISSION, VALUES AND AIMS
4.1. Mission
4.1.1. The mission of Gloucestershire Clinical Commissioning Group is to commission excellent and modern health services on behalf of the NHS for all people in Gloucestershire through effective clinical leadership, with particular focus on patient safety and continuous improvements in the patient experience.
4.1.2. The Group will promote good governance and proper stewardship of public resources in pursuance of its goals and in meeting its statutory duties.
4.2. Values and Aims
4.2.1. Good corporate governance arrangements are critical to achieving the Group’s objectives.
4.2.2. The values/aims that lie at the heart of the Group’s work are to:
. ensure effective communication and engagement with patients, carers, community partners, the public and clinicians; . use our clinical experience to ensure high quality, safe and efficient services for the people of Gloucestershire; . focus on clinical benefit and health outcomes – making best use of the money and resources available; . use our clinical experience to lead innovation, variation, equity and change – right care, right place, right time; and . be accountable and transparent in our decision making.
4.3. Principles of Good Governance
4.3.1. In accordance with section 14L(2)(b) of the 2006 Act,11 the Group will at all times observe “such generally accepted principles of good governance” in the way it conducts its business. These include:
a) the highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the organisation and the conduct of its business;
b) The Good Governance Standard for Public Services;12
c) the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’;13
11 Inserted by section 25 of the 2012 Act 12 The Good Governance Standard for Public Services, The Independent Commission on Good Governance in Public Services, Office of Public Management (OPM) and The Chartered Institute of Public Finance & Accountability (CIPFA), 2004 13 See Appendix G Gloucestershire Clinical Commissioning Group’s Constitution - 13 - Version: 11. Date: September 2016
d) the seven key principles of the NHS Constitution;14
e) the Equality Act 2010;15
f) GCCG will adoptthe adoption of the ‘Standards for Members of NHS Boards and Clinical Commissioning Group governing bodies in England’ issued by the Professional Standards Authority.
4.4. Accountability
4.4.1. The Group will demonstrate its accountability to its members, local people, stakeholders and NHS England in a number of ways, including by:
a) publishing its Constitution;
b) appointing independent Lay Members and other healthcare professionals to its Governing Body;
c) holding meetings of its Governing Body and Primary Care Commissioning Committee in public (except where the Group considers that it would not be in the public interest in relation to all or part of a meeting);
d) meaningful engagement, communication and consultation with the population of Gloucestershire;
e) publishing annually a commissioning plan;
f) complying with local authority health overview and scrutiny requirements;
g) meeting annually in public to present its annual report (which must be published);
h) producing annual accounts in respect of each financial year which must be externally audited;
i) having a published and clear complaints process;
j) complying with the Freedom of Information Act 2000; and
k) providing information to NHS England as required.
4.4.2. In addition to these statutory requirements, the Group will demonstrate its accountability by:
a) publishing a public-facing guide to GCCG setting out its priorities; and
14 See Appendix H 15 See http://www.legislation.gov.uk/ukpga/2010/15/contents Gloucestershire Clinical Commissioning Group’s Constitution - 14 - Version: 11. Date: September 2016
b) a dedicated on-line presence, including social media channels.
4.4.3. The Governing Body of the Group will throughout each year have an on-going role in reviewing the Group’s governance arrangements to ensure that the Group continues to reflect the principles of good governance.
Gloucestershire Clinical Commissioning Group’s Constitution - 15 - Version: 11. Date: September 2016
5. FUNCTIONS AND GENERAL DUTIES
5.1. Functions
5.1.1. The functions that the Group is responsible for exercising are largely set out in the 2006 Act, as amended by the 2012 Act. An outline of these appears in the Department of Health’s Functions of clinical commissioning groups: a working document. They relate to:
a) commissioning certain health services (where NHS England is not under a duty to do so) that meet the reasonable needs of:
i) all people registered with member GP practices, and ii) people who are usually resident within the area and are not registered with a member of any clinical commissioning group;
b) commissioning emergency care for anyone present in the Group’s area;
c) paying its employees’ remuneration, fees and allowances in accordance with the determinations made by its Governing Body and determining any other terms and conditions of service of the Group’s employees; and
d) determining the remuneration and travelling or other allowances of members of its Governing Body.
5.1.2. In discharging its functions the Group will:
a) act16, when exercising its functions to commission health services, consistently with the discharge by the Secretary of State and NHS England of their duty to promote a comprehensive health and wellbeing service17 and with the objectives and requirements placed on the NHS England through the mandate18 published by the Secretary of State before the start of each financial year by:
i) specifying guidelines and policies that set out how GCCG, its committees, sub committees and employees are to exercise, monitor and report on GCCG’s delegated powers and responsibilities; and
ii) the GCCG Clinical Chair being the Vice Chair of Gloucestershire Health & Wellbeing Board (GH&WB), supported by a GP/Other Health Professional (OHP) Clinical Commissioning Lead;
b) meet the public sector equality duty19 by:
16 See section 3(1F) of the 2006 Act, inserted by section 13 of the 2012 Act 17 See section 1 of the 2006 Act, as amended by section 1 of the 2012 Act 18 See section 13A of the 2006 Act, inserted by section 23 of the 2012 Act 19 See section 149 of the Equality Act 2010, as amended by paragraphs 184 and 186 of Schedule 5 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 16 - Version: 11. Date: September 2016
i) encouraging patient experience feedback from communities of interest;
ii) making services accessible and information available in all formats as required through interpretation and translation contracts;
iii) being an active participant at the Health and Care Overview and Scrutiny Committee;
iv) being a member of the Public Sector Partnership;
v) publishing at least annually, sufficient information to demonstrate compliance with this general duty across all GCCG functions;
vi) preparing and publishing specific and measurable equality objectives, revising these at least every four years; and
vii) being committed to the equality agenda and recognising the value of the Equality Delivery Scheme in achieving the public sector equality duty;
c) work in partnership with its local authority[ies] to develop joint strategic needs assessments20 and joint health and wellbeing strategies21by:
i) continue to work with Public Health in refreshing and further developing the Joint Strategic Needs Assessment (JSNA). (The JSNA is accessible from the Group’s website, and is also available on request from GCCG.);
ii) using the JSNA to underpin commissioning decisions and plans; and
iii) working with Gloucestershire Health & Wellbeing Board (GH&WB).
5.2. General Duties - in discharging its functions the Group will:
5.2.1. Make arrangements to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements22 by:
a) adhering to the duties as described in Section 14z2 of the Health & Social Care Act in relation to service change;
b) adopting a Communication and Engagement Strategy;
20 See section 116 of the Local Government and Public Involvement in Health Act 2007, as amended by section 192 of the 2012 Act 21 See section 116A of the Local Government and Public Involvement in Health Act 2007, as inserted by section 191 of the 2012 Act 22 See section 14Z2 of the 2006 Act, inserted by section 26 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 17 - Version: 11. Date: September 2016
c) paying due regard to standards set out in the NHS Constitution in relation to public involvement; and
d) using GCCG toolkit to support engagement in localities.
5.2.2. Promote awareness of, and act with a view to securing that health services are provided in a way that promotes awareness of, and have regard to the NHS Constitution23 by:
a) paying due regard to involvement throughout the communications cycle in order to ensure patient voice influences commissioning intentions;
b) producing a guide for patients on the NHS Constitution (information available on website);
c) continuing to support the role of GCCG GP Public and Patient Involvement Champion;
d) ensuring provider contracts pay due regard to the NHS Constitution; and
e) continuing with the six-monthly stocktake with NHS England on GCCG and all providers.
5.2.3. Act effectively, efficiently and economically24 :
a) See the attached Prime Financial Policies (Appendix F).The Group has approved Prime Financial Policies in order to facilitate the achievement of this aim. (see website and ‘Supporting documents to the Constitution’)
5.2.4. Act with a view to securing continuous improvement to the quality of services25 through:
a) Prime Financial Policies; b) Commissioning for Quality and Innovation (CQUINS) framework; c) robust commissioning contracts; d) Best Practice Tariffs; e) National Institute for Health and Clinical Excellence (NICE) Quality Standards; f) Commissioning Outcomes Frameworks; g) national and local audits; h) Academic Health Science Networks; and i) Quality, Innovation, Productivity and Prevention (QIPP) transformational programmes.
23 See section 14P of the 2006 Act, inserted by section 26 of the 2012 Act and section 2 of the Health Act 2009 (as amended by 2012 Act) 24 See section 14Q of the 2006 Act, inserted by section 26 of the 2012 Act 25 See section 14R of the 2006 Act, inserted by section 26 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 18 - Version: 11. Date: September 2016
5.2.5. Assist and co-commission with NHS England in relation to the Governing Body’s duty to improve the quality of primary medical services26 by:
a) continuously improving the quality of services and the patient experience within primary care, which is a key objective of GCCG, including;
. patient access to services; . patient satisfaction surveys; . clinical audit; . primary care clinical governance arrangements; . patient safety; . health promotion; . reducing health inequalities; . reducing variation; . focusing on clinical benefit and outcomes; . medicines management; and . Peer review and referral management.
5.2.6. Have regard to the need to reduce inequalities27 by:
a) using the JSNA to underpin commissioning decision and plans. (The JSNA is accessible from the Group’s website, and is also available on request from GCCG.); and
b) using the Joint Health and Wellbeing Strategy, using the principles outlined in the Marmot Review (Fair Society, Healthy Lives) on health inequalities. The framework for the Strategy will map to Marmot’s life course approach and address the areas for action set out in ‘Healthy Lives Healthy People’.
5.2.7. Promote the involvement of patients, their carers and representatives in decisions about their healthcare28 by:
a) adopting a quality framework regarding patient experience which requires provider organisations to involve patients, their carers and representatives in decisions about their healthcare;
b) adopting the Individual Funding Request (IFR) process (‘No decision about me without me’);
c) The newoperating Clinical Programme Groups, will be charged with ensuring Public and Patient Involvement Engagement (PPE/PPI) in their work.
5.2.8. Act with a view to enabling patients to make choices29 by:
a) adopting the ‘Choice programme’ and ‘Choose Well Programme’;
26 See section 14S of the 2006 Act, inserted by section 26 of the 2012 Act 27 See section 14T of the 2006 Act, inserted by section 26 of the 2012 Act 28 See section 14U of the 2006 Act, inserted by section 26 of the 2012 Act 29 See section 14V of the 2006 Act, inserted by section 26 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 19 - Version: 11. Date: September 2016
b) adopting the Individual Funding Request (IFR) process (supporting the principle of ‘No decision about me without me’); and
c) providing support to individuals to help them to navigate through the healthcare system.
5.2.9. Obtain appropriate advice30 from persons who, taken together, have a broad range of professional or specialist expertise in health and social care and public health by working with and through:
a) Expert Patient Groups; b) Locality Commissioning Groups and constituent practices; c) Locality Commissioning Lay Members; d) agreeing changes and improvements to clinical services with secondary and tertiary services colleagues through appropriate forums, for example the Clinical Priorities Forum; e) working closely with Public Health professionals; f) working with the Registered Nurse or OHP on the Governing Body to ensure a multi-professional view is sought and incorporated; g) social care services; and h) third sector providers.
5.2.10. Promote innovation31 by:
a) using an evidence-based best practice approach to the commissioning of services; b) ensuring that services commissioned are outcome-focused; c) measuring improvements in patient health and experience; d) keeping abreast of any new advances in technology; e) being proactive in the management of medicines; and f) using tools such as the Annual Operating Plan (AOP), which outlines the opportunities for innovation and quality improvements that CCG intends to implement.
5.2.11. Promote research and the use of research32 by:
a) working with and through the Gloucestershire Research & Development Support Unit (R&DSU); b) improving the environment for health research by facilitating and encouraging sharing of best practice and working with other organisations; and c) supporting the development of services and healthcare practice based upon clear evidence.
30 See section 14W of the 2006 Act, inserted by section 26 of the 2012 Act 31 See section 14X of the 2006 Act, inserted by section 26 of the 2012 Act 32 See section 14Y of the 2006 Act, inserted by section 26 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 20 - Version: 11. Date: September 2016
5.2.12. Have regard to the need to promote education and training33 for persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England so as to assist the Secretary of State for Health in the discharge of his related duty34 by carrying out annual appraisal and personal development review with staff (annual appraisal documentation, guidance notes and training courses are available on the internal website).
5.2.13. Act with a view to promoting integration both of health services with other health services and of health services with health-related and social care services where the group considers that this would improve the quality of services or reduce inequalities35 by being actively involved in:
. Gloucestershire Total Place; . Joint Commissioning Partnership (JCP); . Gloucestershire Health & Wellbeing Board (GH&WB); . Leadership Gloucestershire; . Childrens’ Partnership; and . Safeguarding Boards.
5.3 Joint commissioning arrangements with other Clinical Commissioning Groups
5.3.1 The CCG may wish to work together with other CCGs in the exercise of its commissioning functions.
5.3.2 The CCG may make arrangements with one or more 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.
5.3.3 For the purposes of the arrangements described at paragraph 5.3.2, the CCG may: make payments to another CCG; receive payments from another CCG; 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.
5.3.4 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.
33 See section 14Z of the 2006 Act, inserted by section 26 of the 2012 Act 34 See section 1F(1) of the 2006 Act, inserted by section 7 of the 2012 Act 35 See section 14Z1 of the 2006 Act, inserted by section 26 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 21 - Version: 11. Date: September 2016
5.3.5 For the purposes of the arrangements described at paragraph 5.3.2 above, the CCG may establish and maintain a pooled fund made up of contributions by any of the CCGs working together to jointly commission. 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.
5.3.6 Where the CCG makes arrangements with another CCG as described at paragraph 5.3.2 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; 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; and contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.3.7 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.3.2 above.
5.3.8 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.
5.3.9 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Governing Body.
5.3.10 The Governing Body of the CCG shall require, in all joint commissioning arrangements, that the lead clinician and lead manager of the lead CCG make a quarterly written report to the Governing Body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives.
5.3.11 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, with new arrangements starting from the beginning of the next new financial year.
5.4 Joint commissioning arrangements with NHS England for the exercise of CCG functions
5.4.1 The CCG may wish to work together with NHS England in the exercise of its commissioning functions.
5.4.2 The CCG and NHS England may make arrangements to exercise any of the CCG’s commissioning functions jointly.
Gloucestershire Clinical Commissioning Group’s Constitution - 22 - Version: 11. Date: September 2016
5.4.3 The arrangements referred to in paragraph 5.4.2 above may include other CCGs.
5.4.4 Where joint commissioning arrangements pursuant to 5.4.2 above are entered into, the parties may establish a joint committee to exercise the commissioning functions in question.
5.4.5 Arrangements made pursuant to 5.4.2 above may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.
5.4.6 Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph 5.4.2 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; 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; and contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.4.7 The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph 5.4.2 above.
5.4.8 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.
5.4.9 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body.
5.4.10 The Governing Body of the CCG shall require, in all joint commissioning arrangements, that [insert who]the Director of Commissioning Implementation of the CCG make a quarterly written report to the Governing Body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives.
5.4.11 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, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months notice period.
5.5 Joint commissioning arrangements with NHS England for the exercise of NHS England’s functions
Gloucestershire Clinical Commissioning Group’s Constitution - 23 - Version: 11. Date: September 2016
5.5.1 The CCG may wish to work with NHS England and, where applicable, other CCGs, to exercise specified NHS England functions.
5.5.2 The CCG may enter into arrangements with NHS England and, where applicable, other CCGs to: exercise such functions as specified by NHS England under delegated arrangements; or jointly exercise such functions as specified with NHS England.
5.5.3 Where arrangements are made for the CCG and, where applicable, other CCGs to exercise functions jointly with NHS England, a joint committee may be established to exercise the functions in question.
5.5.4 Arrangements made between NHS England and the CCG may be on such terms and conditions (including terms as to payment) as may be agreed between the parties.
5.5.5 For the purposes of the arrangements described at paragraph 5.5.2 above, NHS England and the CCG may establish and maintain a pooled fund made up of contributions by the parties working together. 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.
5.5.6 Where the CCG enters into arrangements with NHS England as described at paragraph 5.5.2 above, the parties will develop and agree 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; how risk will be managed and apportioned between the parties; financial arrangements, including payments towards a pooled fund and management of that fund; and contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements.
5.5.7 The liability of NHS England to carry out its functions will not be affected where it and the CCG enter into arrangements pursuant to paragraph 5.5.2 above.
5.5.8 The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning.
5.5.9 Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the Governing Body.
5.5.10 The Governing Body of the CCG shall require, in all joint commissioning arrangements that the [insert who]the Director of Commissioning Implementation of the CCG make a quarterly written report to the Governing Body and hold at least
Gloucestershire Clinical Commissioning Group’s Constitution - 24 - Version: 11. Date: September 2016
annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives.
5.5.11 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, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months’ notice period.
5.6 General Financial Duties – the Group will perform its functions so as to:
5.6.1 Ensure its expenditure does not exceed the aggregate of its allotments for the financial year36:
a) See Prime Financial Policies (Appendix F).available on the CCG website.
5.6.2 Ensure its use of resources (both its capital resource use and revenue resource use) does not exceed the amount specified by NHS England for the financial year37:
b) See Prime Financial Policies (Appendix F).available on the CCG website.
5.6.3 Take account of any directions issued by NHS England, in respect of specified types of resource use in a financial year, to ensure the Group does not exceed an amount specified by NHS England. 38
c) See Prime Financial Policies (Appendix F).available on the CCG website.
5.6.4 Publish an explanation of how the Group spent any payment in respect of quality made to it by NHS England39 by:
d) embedding the continuous improvement to the quality of services within contractual agreements and monitoring outputs with all provider types;
e) using the Commissioning for Quality and Innovation (CQUIN) payment framework to reward excellence, by linking a proportion of providers' income to the achievement of local quality improvement goals. The quality goals reflect local priorities, which are stretched and focused. They will concentrate on innovation and improvement to reduce variation and improve outcomes. They are influenced by:
. Local and national priorities; . Commissioner/provider discussions; . Local clinical engagement; . Patient and public engagement and involvement;
36 See section 223H(1) of the 2006 Act, inserted by section 27 of the 2012 Act 37 See sections 223I(2) and 223I(3) of the 2006 Act, inserted by section 27 of the 2012 Act 38 See section 223J of the 2006 Act, inserted by section 27 of the 2012 Act 39 See section 223K(7) of the 2006 Act, inserted by section 27 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 25 - Version: 11. Date: September 2016
. Academic Health Science Networks;
f) in addition to the CQUIN framework, by including key performance and quality indicators within the contracts which are monitored on a monthly basis. Some indicators are nationally mandated, others are locally identified related to specific quality areas where the commissioners would wish to see a year on year improvement in performance;
g) all providers producing annual quality accounts which are reviewed by the GCCG and which will receive a formal sign off; and
h) having, for each main provider contract, a Clinical Quality Review Group. This is a sub group to the Contract Board and reviews quality issues with the provider, identifying any areas of concern, which then require remedial action plans to be implemented. The Group considers progress against CQUIN schemes and output from the provider clinical audit programme, reviews Serious Incidents (SIs) and patient complaints, and oversees Never Events. It will also review the output from any Care Quality Commission (CQC) review and report, ensuring appropriate remedial actions are identified and implemented.
5.7 Other Relevant Regulations, Directions and Documents
5.7.1 The Group will:
a) comply with all relevant regulations;
b) comply with directions issued by the Secretary of State for Health or NHS England; and
c) have regard to guidance issued by NHS England.
5.7.2 The Group will develop and implement the necessary systems and processes to comply with these regulations and directions, documenting them as necessary in this Constitution, its scheme of reservation and delegation and other relevant Group policies and procedures.
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6. DECISION MAKING: THE GOVERNING STRUCTURE
6.1. Authority to act
6.1.1. GCCG is accountable for exercising the statutory functions of the Group. It may grant authority to act on its behalf to:
a) any of its members;
b) its Governing Body;
c) employees; and/or
d) a committee or sub-committee of the Group.
6.1.2. The extent of the authority to act of the respective bodies and individuals depends on the powers delegated to them by the Group as expressed through:
a) the Group’s Scheme of Reservation and Delegation; and
b) for committees, their terms of reference.
6.2. Scheme of Reservation and Delegation40
6.2.1. The Group’s Scheme of Reservation and Delegation will set out:
a) those decisions that are reserved for the membership as a whole; and
b) those decisions that are the responsibilities of its Governing Body, the Group’s committees and sub-committees, individual members and employees.
6.2.2. Gloucestershire Clinical Commissioning Group remains accountable for all of its functions, including those that it has delegated.
6.3. General
6.3.1. In discharging functions of the Group that have been delegated to them, its Governing Body (and its committees)41 and individuals must:
a) comply with the Group’s principles of good governance:42
b) operate in accordance with the Group’s Scheme of Reservation and Delegation;43
40 See Appendix D 41 See CCG Proposed Structure in Appendix GJ. 42 See section 4.4 on Principles of Good Governance above 43 See appendix D Gloucestershire Clinical Commissioning Group’s Constitution - 27 - Version: 11. Date: September 2016
c) comply with the Group’s Standing Orders;,44
d) comply with the Group’s arrangements for discharging its statutory duties45; and
e) where appropriate, ensure that member practices have had the opportunity to contribute to the Group’s decision making process.
6.3.2. When discharging their delegated functions, committees, sub-committees and joint committees must also operate in accordance with their approved terms of reference.
6.3.3. Where delegated responsibilities are being discharged collaboratively, the joint (collaborative) arrangements must:
a) identify the roles and responsibilities of those clinical commissioning groups who are working together;
b) identify any pooled budgets and how these will be managed and reported in annual accounts;
c) specify under which clinical commissioning group’s Scheme of Reservation and Delegation and supporting policies the collaborative working arrangements will operate;
d) specify how the risks associated with the collaborative working arrangement will be managed between the respective parties;
e) identify how disputes will be resolved and the steps required to terminate the working arrangements; and
f) specify how decisions are communicated to the collaborative partners.
6.4. Committees of the Group
6.4.1. Committees will only be able to establish their own sub-committees, to assist them in discharging their respective responsibilities, if this responsibility has been delegated to them by the Group or the committee they are accountable to.
6.5. Joint Arrangements
6.5.1 See Appendix JG for a diagram showing the CCG’s Governance Structure.
6.5.2 GCCG will delegate authority to members or employees participating in joint arrangements to make decisions on its behalf (the Group thereby retaining accountability for such decision). Therefore, it will be the individual member /
44 See appendix C 45 See chapter 5 above Gloucestershire Clinical Commissioning Group’s Constitution - 28 - Version: 11. Date: September 2016
employee who has the delegated authority to make a decision rather than any joint arrangement.
6.5.3 The Group has joint committees with the following local authority(ies):
a) Joint Commissioning Boards for Adults, Children, Mental Health and Learning Disabilities with Gloucestershire County Council.
6.6. The Governing Body
6.6.1 Functions - the Governing Body has the functions conferred on it by sections 14L(2) and (3) of the 2006 Act, inserted by section 25 the 2012 Act, together with any other functions connected with its main functions as may be specified in regulations:46
a) ensuring that the Group has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the groups principles of good governance47 (its main function);
b) determining the remuneration, fees and other allowances payable to employees or other persons providing services to the Group and the allowances payable under any pension scheme it may establish under paragraph 11(4) of Schedule 1A of the 2006 Act, inserted by Schedule 2 of the 2012 Act;
c) approving any functions of the Group that are specified in regulations;48that the membership will delegate to their Governing Body;
d) ensuring that the register(s) of interest is reviewed regularly, and updated as necessary; and
e) ensuring that all conflicts of interest or potential conflicts of interest are declared.
6.6.2 Quorum - Any quorum of GCCG or it sub-committees shall exclude any member affected by a conflict of interest. If this paragraph has the effect of rendering the meeting inquorate, then the Chair shall decide whether to adjourn the meeting to permit the appointment or co-option of additional members.
6.6.3 Eligibility to Serve - People who are ineligible for appointment to the GCCG Governing Body include anyone who:
is not eligible to work in the UK; has received a prison sentence or suspended sentence of 3 months or more in the last 5 years; is the subject of a bankruptcy order or interim order;
46 See section 14L(3)(c) of the 2006 Act, as inserted by section 25 of the 2012 Act 47 See section 4.4 on Principles of Good Governance above 48 See section 14L(5) of the 2006 Act, inserted by section 25 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 29 - Version: 11. Date: September 2016
has been dismissed (except by redundancy) by any NHS body; is subject to a disqualification order set out under the Company Directors Disqualification Act 1986; or has been removed from acting as a trustee of a charity.
6.6.4 Composition of the Governing Body - the Governing Body shall not have less than 18 19 and (in line with national guidance) will include some or all of:
Clinical Chair; Deputy Clinical Chair; Vice Chair (Lay Member - Patient Public Engagement); Accountable Officer (AO); Director of Commissioning Implementation (and Deputy AO); Chief Finance Officer (CFO); Seven GP Clinical Commissioning Leads or Other Healthcare Professional (OHP) Clinical Commissioning Leads; A minimum of three lay members covering Patient Public Engagement, Business and Governance; Director of Public Health; Secondary Care Specialist; Registered Nurse; Director of Adult Social Care; Director of Transformation and Service Redesign; Director of Locality Development and Primary Care; Executive Nurse and Quality Lead; and Director of Integration (non-voting.
6.6.5 Appointment of the Clinical Chair and Vice Chair of the Governing Body
The Clinical Chair and Deputy Clinical Chair shall serve on the GCCG Governing Body for a period in accordance with national guidance after which the positions shall be subject to reappointment. No Clinical Chair shall serve on the Governing Body for a period that exceeds national guidance without a break as specified in national guidance.
The Clinical Chair and Deputy Clinical Chair will be subject to national assessment and local appointment.
Where the Clinical Chair is a GP, the Vice Chair shall be a lay member.
The roles of the Clinical Chair and Accountable Officer shall not be held by the same individual.
The Chairs of the Audit Committee and/or the Remuneration Committees could be the Vice Chair of the Governing Body but would be precluded from being its Clinical Chair.
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Where the Clinical Chair of the Governing Body is also the senior clinical voice of the Group that person will take the lead in interactions with stakeholders, including NHS England.
6.6.6 In respect of the Governing Body, subject to provision made in regulations, GCCG will set out in its Standing Orders:
how the Group will appoint such members of the Governing Body;
the tenure of office;
how such a person would resign from their post;
the grounds for removal from office.
6.6.7 The Clinical Chair and Deputy Clinical Chair; The procedure for appointing the Clinical Chair and Deputy Clinical Chair of the Governing Body, is set out in the Group’s Standing Orders (see Appendix C of this Constitution) and is subject to national guidance.
6.6.8 Seven GP/OHP Clinical Commissioning Leads acting on behalf of member practices; The procedure for appointing the GP/OHP Clinical Commissioning Leads acting on behalf of members practices of the Governing Body, is set out in the Group’s Standing Orders (see Appendix C of this Constitution).
6.6.9 A minimum of three lay members; one to lead on audit, remuneration and conflict of interest matters; one to lead on patient and public engagement (and appointed as Non-clinical Vice-Chair) and one to lead on business.
6.6.10 The procedure for appointing the lay members of the Governing Body is set out in the Group’s Standing Orders (subject to national guidance).- see Appendix C of this Constitution).
6.6.11 One Registered Nurse; The procedure for appointing the Registered Nurse of the Governing Body is set out in the Group’s Standing Orders (see Appendix C of this Constitution).
6.6.12 One Secondary Care Specialist; The procedure for appointing the Secondary Care Specialist of the Governing Body is set out in the Group’s Standing Orders (see Appendix C of this Constitution).
6.6.13 The Accountable Officer (Manager)
6.6.14 The Chief Finance Officer (Manager)
6.6.15 Other individuals who do not fall into the above categories; Director of Adult Social Care and Director of Public Health.
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6.6.16 Committees of the Governing Body - the Governing Body has appointed the following committees and sub-committees, the terms of reference for which can be found on the CCG website:
a) Audit Committee – The Audit Committee, which is accountable to the Group’s Governing Body, provides the Governing Body with an independent and objective view of the Group’s financial systems, financial information and compliance with laws, regulations and directions governing the Group in so far as they relate to finance. The Governing Body has approved, keeps under review and may amend the terms of reference for the Audit Committee, which includes information on the membership of the Committee49. Changes to the Audit Committee terms of reference must be approved by the Governing Body.
In addition the Group or the Governing Body has conferred or delegated a number of functions, connected with the Governing Body’s main function50, to its Audit Committee (see Appendix K).. The Audit Committee will fulfil the role of ‘Auditor Panel’, as defined in the Local Audit and Accountability Act 2014.
b) Remuneration Committee – The Remuneration Committee, which is accountable to the Group’s Governing Body, makes recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the Group and on determinations about allowances under any pension scheme that the Group may establish as an alternative to the NHS pension scheme. The Governing Body has approved, keeps under review and may amend the terms of reference for the Remuneration Committee, which includes information on the membership of the Committee51. Changes to the Remuneration Committee terms of reference must be approved by the Governing Body.
In addition the Group or the Governing Body has conferred or delegated a number of functions, connected with the Governing Body’s main function, to its Remuneration Committee. (see Appendix L).
c) Integrated Governance and Quality Committee (IGQC)52 - The aim of the Integrated Governance and Quality Committee is to continuously improve the delivery of healthcare services to the people of Gloucestershire, so ensuring that the services are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements. The Committee will ensure that controls are in place and are operating efficiently and effectively to deliver the principal objectives of the Governing Body and to set in place
49 See appendix K the website for the terms of reference of the Audit Committee 50 See section 14L(2) of the 2006 Act, inserted by section 25 of the 2012 Act 51 See appendix L the website for the terms of reference of the Remuneration Committee 52 See appendix M the website for the terms of reference of the Integrated Governance and Quality Committee Gloucestershire Clinical Commissioning Group’s Constitution - 32 - Version: 11. Date: September 2016
processes to manage identified risks, minimising the Clinical Commissioning Group’s exposure to corporate and clinical risks. The Committee will have a pro-active approach to the management of risk and quality, ensuring the organisation learns and takes appropriate corrective action.The Governing Body has approved, keeps under review and may amend the terms of reference for the Integrated Governance and Quality Committee, which includes information on the membership of the Commissioning for Quality Group (CfQG), which has been established to help the IGQC discharge its duties and powers.: see Appendix M. The aim of the Integrated Governance and Quality Committee is to continuously improve the delivery of healthcare services to the people of Gloucestershire, so ensuring that the services are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements. The Committee will ensure that controls are in place and are operating efficiently and effectively to deliver the principal objectives of the Governing Body and to set in place processes to manage identified risks, minimising the Clinical Commissioning Group’s exposure to corporate and clinical risks. The Committee will have a pro-active approach to the management of risk and quality, ensuring the organisation learns and takes appropriate corrective action. Changes to the IGQC terms of reference must be approved by the Governing Body.
d) Priorities Committee53 - The purpose of the Priorities Committee is to advise the local NHS health economy as to the health care interventions and policies that should be given high or low priority. The Priorities Committee helps the CCG and its Localities choose how to allocate its resources to promote the health of the local community, based on the local health needs assessment.The Governing Body has approved, keeps under review and may amend the terms of reference for the Priorities Committee. The purpose of the Priorities Committee is to advise the local NHS health economy as to the health care interventions and policies that should be given high or low priority. The Priorities Committee helps the CCG and its Localities choose how to allocate its resources to promote the health of the local community, based on the local health needs assessment. The Terms of Reference for the priorities Committee are shown at Appendix N. Changes to the Priorities Committee terms of reference must be approved by the Governing Body.
e) Primary Care Commissioning Committee54 - The purpose of this Committee is to oversee the exercise of the delegated primary care commissioning functions. The Governing Body has approved, keeps under review and may amend the terms of reference for the Primary Care Commissioning Committee. The purpose of this Committee is to oversee the exercise of the delegated primary care commissioning functions. The Terms of Reference of the Committee are shown at Appendix O. Changes to the Primary Care Commissioning Committee terms of reference must be approved by the Governing Body. Members of the Committee that may be
53 See appendix Nwebsite for the terms of reference of the Priorities Committee 54 See website for the terms of reference of the Primary Care Commissioning Committee Gloucestershire Clinical Commissioning Group’s Constitution - 33 - Version: 11. Date: September 2016
appointed who are not members of the Governing Body, or employees of the CCG, will comply with this Constitution and the CCG’s policies for the management of conflicts of interest.
7. ROLES AND RESPONSIBILITIES
7.1 Gloucestershire Clinical Commissioning Group (GCCG)
7.1.1 A key part of GCCG’s commitment is to build GCCG as a ‘membership organisation’.
7.1.2 GCCG membership comprises 85 81 practices from seven constituent localities. Each locality appoints one of the GPs or other healthcare professionals in the constituent practices to lead and chair the locality, and to sit as a member of the Governing Body as a GP Clinical Commissioning Lead or OHP Clinical Commissioning Lead. A locality’s GP/OHP Clinical Commissioning Lead chairs and holds regular meetings involving the Commissioning Leads from each constituent practice of the locality.
7.2 GCCG Role will be to:
. set a commissioning strategy and policy (which is responsive to the needs assessment and priorities for the population and reflects the views of individual localities);
. implement a clinical strategy using a co-production approach and defining quality outcomes and best value that meets the needs of our population;
. be clinical leaders - engaging member practices and the wider clinical community;
. establish governance arrangements that establish GCCG as a membership organisation;
. establish and lead a clinical programme-based approach to commissioning;
. ensure transparency and accountability with decision making:
. manage devolved commissioning budgets; and
. support localities with the development of programmes and projects agreed with GCCG and where appropriate holding localities and others to account for delivery.
7.3 Locality Executive Groups
7.3.1 There is a need to review and strengthen engagement with constituent practices through the seven localities:
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. Cheltenham; . Forest of Dean; . Gloucester City; . North Cotswolds; . South Cotswolds; . Stroud and Berkeley Vale; . Tewkesbury.
7.3.2 The establishment of localities was a key part of GCCG’s commitment to building a ‘membership organisation’.
7.3.3 A county-wide clinical commissioning group has been agreed with seven constituent localities, each with a Locality Lead (i.e. GP or OHP) who will act as a conduit for the views of the locality on behalf of member practices sitting on GCCG. Each locality is chaired by a GP/OHP Clinical Commissioning Lead, has an executive and holds regular meetings involving the commissioning leads from each practice. This is in addition to other regular development sessions (including Practice Learning Time) and locality-specific project groups. 55Terms of Reference for Locality Executive Groups can be found at Appendix O (included in the ‘Supporting documents to the Constitution’ on the CCG’s website).
7.3.4 The commitment to the continuation of localities was designed to ensure:
. two way engagement with constituent practices – sharing Gloucestershire wide developments, ensuring a two-way conversation on key issues, including monthly locality meetings and an annual member practice council meeting:
. a locality approach to delivery of key service developments and a means to pilot new approaches;
. continuity – in particular building on Practice Based Commissioning (PbC) as a mechanism for budgetary management;
. a focus for local service developments and Quality, Innovation, Productivity and Prevention (QIPP) delivery (including the management of demand); and
. maintain support to the PbC localities and ensuring good links with the local community, including Local Strategic Partnerships (LSPs), Councils and others.
7.3.5 Arrangements have been designed to increase the level of practice engagement to fulfil GCCG’s ambition to establish a vibrant membership organisation.
7.4 Communications Approach
55 See appendix O for the terms of reference for Locality Executive Groups Gloucestershire Clinical Commissioning Group’s Constitution - 35 - Version: 11. Date: September 2016
7.4.1 GCCG will be responsible for ensuring that patients and the public are properly consulted and involved in the commissioning cycle. This will include publishing a Communication and Engagement Strategy. The Communication and Engagement Strategy sets out how GCCG will communicate and engage with the local population including key stakeholders such as patients, carers, community representatives, the clinical community and the media.
7.4.2 GCCG will produce an e-bulletin, in addition to the prescribing newsletter published each month with key messages for practices hoping to reach all clinical staff and Practice Managers and will include links to further detail.
7.4.3 Face-to-face events such as commissioning and prescribing events support two- way communication and engagement. 7.4.4 Opportunities will be put in place using events planned for member practice representatives to meet with the locality executives of GCCG to discuss the activities and plans of GCCG. 7.4.5 The Clinical Leads are important ambassadors for GCCG and part of the communication structure. We anticipate that they will beThey are supported in work-streams by other member clinicians, particularly those with a special interest. This will encourage a bottom-up approach to service redesign.
7.4.6 It is important to have close links with the Practice Managers’ Group to capture their knowledge and expertise. They are a vital resource when communicating with practices and effecting change. Using the Practice Managers’ Network, it is anticipated Practice Managers will work collectively in their roles with GCCG to identify common issues and opportunities, feedback at locality level and to communicate and work with GCCG.
7.4.7 Community pharmacists and the Information Team will work with practices to understand both demand and capacity. Practice support pharmacists will work with practices to encourage and support safe and cost effective prescribing. Both will offer informal opportunities for communication regarding GCCG work.
7.4.8 GCCG is committed to expanding this approach to other areas of practice performance and the approach to comparing and reviewing practice will look at the following principles: . a need to understand and where appropriate minimise variation; . to support cost effective use of resources; . to optimise health outcomes; and . to reduce health inequalities.
7.5 Role of GP/OHP Clinical Commissioning Leads:
7.5.1 The GP/OHP Clinical Commissioning Lead from each locality will play an important role in locality engagement as well as taking on a lead role on county- wide projects. GCCG will be responsible for supporting each Lead in a locality role and in specialist lead areas. The GP/OHP Clinical Commissioning Leads:
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. provide a two-way engagement route for the Governing Body to communicate with practices and to gain practice input into the work of GCCG;
. act as a vital source of intelligence for GCCG – on local health needs, the reality of services on the ground, etc.;
. focus for devolved commissioning budget management – share performance information with practices and where appropriate challenge practice;
. act as a vehicle to translate county-wide commissioning plans into ‘operationalised’ locality plans;
. pilot new approaches; and
. liaise with local councillors, local people and the local tertiary sector.
7.6 Practice Representatives
7.6.1 Practice representatives represent their practice’s views and act on behalf of the practice in matters relating to the Group. The role of each practice is to:
. nominate commissioning and prescribing leads to:
a) represent the practice at GCCG/locality meetings; and
b) represent the needs of the practice’s patient population within the GCCG;
. actively engage with GCCG to help improve services within the area;
. share all appropriate information and data and any other data relating to commissioning priorities to support delivery of equitable quality care of referral and other prescribing and emergency admissions data;
. adopt the Clinical Programme Group approach, and follow the clinical pathways and referral protocols agreed by GCCG (except in individual cases where there are justified clinical reasons for not doing this) which are fed back appropriately;
. manage the practice’s prescribing budget within allocated resources;
. participate in and deliver, as far as possible, the clinical, quality, safety effectiveness (and cost effective) strategies agreed by GCCG and GH&WB;
. establish a practice reference group and other means determined, to obtain the views and experiences of patients and carers;
. work constructively with the locality sub-committee/GCCG; and Gloucestershire Clinical Commissioning Group’s Constitution - 37 - Version: 11. Date: September 2016
. respond in a timely manner to reasonable commissioning-related information requests from GCCG.
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7.7 Memorandum of Agreement
7.7.1 The effective participation of each member practice will be essential in developing and sustaining high quality commissioning arrangements.
7.7.2 A Memorandum of Agreement between individual member practices and GCCG clarifies the expectations and obligations of both parties56.
7.7.3 The Memorandum of Agreement will document any commissioning agreements reached between the member practice and GCCG and will be the formal mechanism for determining eligibility to any future incentive payment (currently referred to as the Quality Premium). Accordingly it will be updated on an annual basis.
7.7.4 The Memorandum of Agreement includes:
. Parties to the Agreement; . Values, Aims and Mission of GCCG; . Commissioning responsibilities of the member practices; . Responsibilities of GCCG; . Annual commissioning objectives/targets agreed with the member practices; . Monitoring arrangements and frequency of meetings; . Practice budgets of the member practices; . Dispute resolution; . Review of the Agreement; and . Signatures to the Agreement.
7.8 Other Key Roles
7.8.1 GCCG will have, at times, specific ‘tasks’ where it will need GP or other healthcare professional input, working on behalf of GCCG. This will be on a voluntary basis where individuals are keen to be involved and/or are interested in the subject matter and where their practice is agreeable to them participating. Where this is deemed to be significant, and outside the role of normally-funded activities and/or responsibilities funded by the commissioning Locally Enhanced Service (LES), then GCCG will provide limited remuneration or backfill to allow full participation in the task on a time limited basis.
7.8.2 By using GPs and other healthcare professionals in this way, GCCG aspires to gain involvement from a broader membership of primary care in developing and delivering its work programme than just those members involved in GCCG and the executive leadership of the localities.
7.8.3 When working for GCCG, individuals from practices will need to be aware of GCCG policies and work within them. Specific attention is drawn to the Standards of Business Conduct policy57.
56 See appendix HP - terms of reference for Memorandum of Understanding Gloucestershire Clinical Commissioning Group’s Constitution - 39 - Version: 11. Date: September 2016
7.9 All Members of GCCG’s Governing Body
7.9.1 The Governing Body shall consist of a maximum of 23 membersminimum of 19 members, as set out in paragraph 6.6.4.
7.9.2 All members of the Governing Body will share responsibility in ensuring that GCCG exercises its functions effectively, efficiently and with good governance and in accordance with the terms of GCCG’s Constitution as agreed by its members.
7.9.3 This Constitution and any future iterations of it will be publicly available on GCCG’s website, and will also be available on request from GCCG.
7.9.4 Individual members will bring their unique perspective, informed by their expertise and experience. This will underpin decisions made by the Governing Body and will help ensure that as far as reasonably practicable:
. the values and principles of the NHS Constitution are actively promoted; . the interests of patients and the community remain at the heart of discussions and decisions; . the Governing Body and the wider GCCG acts in the best interests of the local population at all times; . GCCG commissions the highest quality services and best possible outcomes for their patients within their resource allocation; and . good governance remains central at all times.
7.10 Clinical Chair of the Governing Body
7.10.1 The Clinical Chair of the Governing Body is responsible for:
. leading the Governing Body, ensuring it remains continuously able to discharge its duties and responsibilities; . building and developing the Group’s Governing Body and its individual members; . ensuring that the Group has proper constitutional and governance arrangements in place; . ensuring that, through the appropriate support, information and evidence, the Governing Body is able to discharge its duties; . supporting the Accountable Officer in discharging the responsibilities of the organisation; . contributing to building a shared vision of the aims, values and culture of the organisation; . leading and influencing to achieve clinical and organisational change to enable the Group to deliver its commissioning intentions;
57 See Section 8 Standards of Business conduct and Managing Conflicts of Interest Gloucestershire Clinical Commissioning Group’s Constitution - 40 - Version: 11. Date: September 2016
. overseeing governance and particularly ensuring that the Governing Body and the wider Group behave with the utmost transparency and responsiveness at all times; . ensuring that public and patients’ views are heard and their expectations understood and, as far as possible, met; . ensuring that the organisation is able to account to its local patients, stakeholders and NHS England; and . ensuring that the group builds and maintains effective relationships, particularly with the Gloucestershire Health and Wellbeing Board (GH&WB).
7.11 The Deputy ClinicalVice Chair of the Governing Body
7.11.1 The Deputy ClinicalVice Chair of the Governing Body deputises for the Chair of the Governing Body where he or she has a conflict of interest or is otherwise unable to act.
7.12 Role of the Accountable Officer
7.12.1 The Accountable Officer of the Group is a member of the Governing Body.
7.12.2 The Governing Body will select and appoint an Accountable Officer following ratification by NHS England. The Accountable Officer will be an ex-officio member of the Governing Body.
7.12.3 The Accountable Officer will have specific responsibilities for ensuring that GCCG complies with its financial duties, promotes quality improvements and demonstrates value for money.
7.12.4 The Accountable Officer must be either:
. a GP who is a member of GCCG; . an employee of GCCG or any member of GCCG; or . in the case of a joint appointment, an employee or any member of any of the groups in question or any member of those groups.
7.12.5 The Accountable Officer will be responsible for ensuring that GCCG fulfils its duties to exercise its functions effectively, efficiently and economically thus ensuring improvement in the quality of services and the health of the local population whilst maintaining value for money.
7.12.6 The Accountable Officer will ensure that the regularity and propriety of expenditure is discharged, and that arrangements are put in place to ensure that good practice (as identified through such agencies as the Audit Commission and the National Audit Office) is embodied and that safeguarding of funds is ensured through effective financial and management systems.
7.12.7 The Accountable Officer will work closely with the Chair of the Governing Body and will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Gloucestershire Clinical Commissioning Group’s Constitution - 41 - Version: 11. Date: September 2016
Body) of the organisation’s on-going capability and capacity to meet its duties and responsibilities. This will include arrangements for the on-going developments of its members and staff.
7.12.8 In addition to the Accountable Officer’s general duties, where the Accountable Officer is also the senior clinical voice of the group he or she will take the lead in interactions with stakeholders, including NHS England.
7.13 Role of the Chief Finance Officer
7.13.1 The Chief Finance Officer is a member of the Governing Body and is responsible for providing financial advice to the Clinical Commissioning Group and for supervising financial control and accounting systems.
7.13.2 This role of Chief Finance Officer has been summarised in a national document58 as:
a) being the Governing Body’s professional expert on finance and ensuring, through robust systems and processes, the regularity and propriety of expenditure is fully discharged;
b) making appropriate arrangements to support and monitor the Group’s finances;
c) overseeing robust audit and governance arrangements leading to propriety in the use of the Group’s resources;
d) being able to advise the Governing Body on the effective, efficient and economic use of the Group’s allocation to remain within that allocation and deliver required financial targets and duties; and
e) producing the financial statements for audit and publication in accordance with the statutory requirements to demonstrate effective stewardship of public money and accountability to NHS England.
7.14 Role of Lay Members
7.14.1 There are a minimum of three lay members appointed to the Governing Body, : one with responsibility for audit, remuneration and conflict of interest matters, one with responsibility for patient and public participation matters (and acts as non-clinical Vice Chair), and one with responsibility for business matters.
7.14.2 The role and focus of the lay member with responsibility for audit, remuneration and conflict of interest matters is strategic and impartial, to provide an external view of the work of GCCG that is removed from the day-to-day running of the organisation. Specific responsibilities include:
58 See the latest version of the NHS Commissioning Board Authority’s Clinical commissioning group governing body members: Role outlines, attributes and skills Gloucestershire Clinical Commissioning Group’s Constitution - 42 - Version: 11. Date: September 2016
. overseeing key elements of governance including audit, remuneration and managing conflicts of interest;
. chairing the Audit Committee; ensuring that the Governing Body and the wider CCG behaves with the utmost probity at all times; and
. ensuring that appropriate and effective whistle blowing and anti-fraud systems are in place.
7.14.3 The lay member with responsibility for patient and public participation matters will be a member of the local community and bring that insight to the work of the Governing Body. This member will ensure that for all aspects of GCCG’s business, the public voice of the local population is heard and that opportunities are created and protected for patient and public empowerment in the work of the CCG. Specific responsibilities include ensuring that:
. public and patients’ views are heard and their expectations understood and met as appropriate;
. the CCG builds and maintains an effective relationship with Local HealthWatch and draws on existing patient and public engagement and involvement expertise; and
. the CCG has appropriate arrangements in place to secure public and patient involvement and responds in an effective and timely way to feedback and recommendations from patients, carers and the public.
7.14.4 The lay member with responsibility for business matters will be a member of the local business community and bring that insight to the work of the Governing Body. This member will be removed from the day-to-day running of the organisation, but will have specific responsibility fories ensuring that:
. a robust business infrastructure exists and oversees key elements of business including the development of business plans and conflicts of interestcontributing to the CCG’s understanding of business systems and processes;
. bringing a commercial expertise and understanding to the CCG’s strategy for commissioning services from both NHS and non-NHS providersact as a specialist reference point in business management; and
. helping the CCG to strengthen engagement with the business sector within Gloucestershire as a key partner in delivering the CCG’s strategic plans.understand the impact and operational demands of delivering GCCG strategic priorities in the annual integrated plan, and oversees budgeting decisions around key projects.
7.15 Role of the Registered Nurse
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7.15.1 The Registered Nurse on the Governing Body is to be filled by a qualified individual with a high level of professional expertise and knowledge. A key aspect of the role is to bring a broader view, from their perspective as a registered nurse, on health and care issues to underpin the work of the Group, especially the contribution of nursing to patient care. Specific responsibilities include:
. giving an independent strategic clinical view on all aspects of CCG business;
. bringing detailed insights from nursing and perspectives into discussions regarding service re-design, clinical pathways and system reform.
7.16 Role of the Secondary Care Specialist
7.16.1 The purpose of the secondary care specialist is to bring an understanding of patient care in the secondary care setting to the work of the Governing Body. The individual appointed will have a high level of understanding of how care is delivered in a secondary care setting, preferably with experience working as a leader across more than one clinical discipline and/or specialty with a track record of collaborative working. A specific aspect of this role involves bringing appropriate insight to discussions regarding service redesign, clinical pathways and system reform.
7.17 Joint Appointments with other Organisations
7.17.1 At present GCCG does not have any joint appointments with other organisations.
7.17.12 Should joint appointments be made in the future, these joint appointments will be supported by a memorandum of understanding between the organisations who are party to these joint appointments.
7.17.2 All joint appointments will recognise national regulations and guidance regarding conflicts of interest and be in accordance with the CCG’s Standards of Business Conduct policy.
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8. STANDARDS OF BUSINESS CONDUCT AND MANAGING CONFLICTS OF INTEREST
8.1. Standards of Business Conduct
8.1.1. Employees, contractors, members, committee and sub-committee members of the Group and members of the Governing Body (and its committees) will at all times comply with this Constitution and be aware of their responsibilities as outlined in it. They should act in good faith and in the interests of the Group and should follow the Seven Principles of Public Life, set out by the Committee on Standards in Public Life (the Nolan Principles). The Nolan Principles are incorporated into this constitution at Appendix EG.
8.1.2. They must comply with the Group’s Standards of Business Conduct policy on business conduct, including the requirements set out in the policy for managing conflicts of interest. This policy is available on the Group’s website, and is also available on request from GCCG.
8.1.3. Individuals contracted to work on behalf of the Group or otherwise providing services or facilities to the Group will be made aware of their obligations with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services.
8.2. Conflicts of Interest
8.2.1. GPs who serve on GCCG also work for, or are partners running, general medical practices in the county. For the avoidance of doubt, in what follows there will be no prima facie conflict of interest sufficient to require It is the responsibility of the Chair of the meeting concerned to decides if a GP member of GCCG to should withdraw from any discussion of services to be commissioned by GCCG from general medical practices if the service is to be offered to more practices than those to which the member, or members, involved in the discussion belong.
8.2.2. As required by section 14O of the 2006 Act, as inserted by section 25 of the 2012 Act, GCCG will make arrangements to manage conflicts and potential conflicts of interest to ensure that decisions made by the Group will be taken and seen to be taken without any possibility of the influence of external or private interest.
8.2.3. Where an individual, i.e. an employee, Group member, member of the Governing Body, or a member of a committee or a sub-committee of the Group or its Governing Body has an interest, or becomes aware of an interest which could lead to a conflict of interest in the event of the Group 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.
8.2.4. A conflict of interest will include:
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a) a direct pecuniary interest: where an individual may financially benefit from the consequences of a commissioning decision (for example, as a provider of services);
b) an indirect pecuniary interest: for example, where an individual is a partner, member or shareholder in an organisation that will benefit financially from the consequences of a commissioning decision;
c) a non-pecuniary interest: where an individual holds a non-remunerative or not-for-profit interest in an organisation, that will benefit from the consequences of a commissioning decision (for example, where an individual is a trustee of a voluntary provider that is bidding for a contract);
d) a non-pecuniary personal benefit: where an individual may enjoy a qualitative benefit from the consequence of a commissioning decision which cannot be given a monetary value (for example, a reconfiguration of hospital services which might result in the closure of a busy clinic next door to an individual’s house);
a) Financial interests: This is where an individual may get direct financial Formatted: Outline numbered + Level: 4 + Numbering Style: a, b, c, … benefit from the consequences of commissioning decision; + Start at: 1 + Alignment: Left + Aligned at: 2 cm + Tab after: 2.8 cm b) Non-financial professional interests: This is where an individual may obtain + Indent at: 2.8 cm non-financial professional benefits from the consequences of commissioning Formatted: Left, Indent: Left: 1.27 decisions, such as increasing their professional reputation or status or cm, No bullets or numbering promoting their professional career; Formatted: Outline numbered + Level: 4 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + c) Non-financial personal interests: This is where an individual may benefit Aligned at: 2 cm + Tab after: 2.8 cm + Indent at: 2.8 cm personally in ways which are not directly linked to their professional career Formatted: Left, Indent: Left: 1.27 and do not give rise to direct financial benefits; cm, No bullets or numbering
Formatted: Outline numbered + d) Indirect interests: This is where an individual has a close association with an Level: 4 + Numbering Style: a, b, c, … individual who has a financial interest, a non-financial professional interest, + Start at: 1 + Alignment: Left + Aligned at: 2 cm + Tab after: 2.8 cm or a non-financial personal interest in a commissioning decision; + Indent at: 2.8 cm Formatted: Left, Indent: Left: 1.27 e) any duty whatsoever imposed on any member of the Governing Body or its cm, No bullets or numbering sub-committees’, CCG members/clinicians by any other codes of conduct to Formatted: Outline numbered + Level: 4 + Numbering Style: a, b, c, … which the member is subject; + Start at: 1 + Alignment: Left + Aligned at: 2 cm + Tab after: 2.8 cm + Indent at: 2.8 cm f) any other interest whatsoever that should be dutifully declared under The Formatted: Indent: Left: 2.8 cm, First Health and Social Care Act 2012 and guidance issued by Department of line: 0 cm, Tab stops: Not at 2.75 cm Health from time to time;
g) where an individual is closely related to, or in a relationship, including friendship, with an individual in the above categories.
h)g) if the individual is registered with the General Medical Council (GMC), any interest that the individual would be required to declare in accordance with paragraph 55 of the GMC’s publication “Management for Doctors” or any Gloucestershire Clinical Commissioning Group’s Constitution - 46 - Version: 11. Date: September 2016
successor code, including the referral of any patient to a provider in which the individual has an interest; and
i)h) if the individual is registered with the Nursing and Midwifery Council (NMC) or other professional body would be required to declare in accordance with paragraph 7 of the NMC’s publication Code of Professional Conduct or any successor code including the referral of any patient to a provider in which the individual has an interest.
8.2.5. If in doubt, the individual concerned should assume that a potential conflict of interest exists.
8.3. Declaring and Registering Interests
8.3.1. The Group will maintain one or more registers of the interests of:
a) the members of the Group;
b) the members of its Governing Body;
c) the members of its committees or sub-committees and the committees or sub-committees of its Governing Body; and
d) its employees and contractors.
8.3.2. The registers will be published on the Group’s website, and will also be available on request from GCCG.
8.3.3. Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of the Group, in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware.
8.3.4. Where an individual is unable to provide a declaration in writing, for example, if a conflict becomes apparent in the course of a meeting, they will make an oral declaration before witnesses, and provide a written declaration as soon as possible thereafter.
8.3.5. The Accountable Officer will ensure that the registers of interest are reviewed regularly, and updated as necessary.
8.4. Managing Conflicts of Interest: general
8.4.1. Individual members of the Group, the Governing Body, committees or sub- committees and employees will comply with the arrangements determined by the Group for managing conflicts or potential conflicts of interest.
8.4.2. The Accountable Officer will oversee the management of conflicts of interest on behalf of the Group and will ensure that for every interest declared, either in
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writing or by oral declaration, arrangements are in place to manage the conflict of interests or potential conflict of interests, to ensure the integrity of the Group’s decision making processes.
8.4.3. Arrangements for the management of conflicts of interest are to be determined by the Accountable Officer and will include the requirement to put in writing to the relevant individual arrangements for managing the conflict of interests or potential conflicts of interests, within a week of declaration. The arrangements will confirm the following:
a) when an individual should withdraw from a specified activity, on a temporary or permanent basis; and
b) monitoring of the specified activity undertaken by the individual, either by a line manager, colleague or other designated individual.
8.4.4. Where an interest has been declared, either in writing or by oral declaration, the declarer will ensure that before participating in any activity connected with the Group’s exercise of its commissioning functions, they have received confirmation of the arrangements to manage the conflict of interest or potential conflict of interest from the Accountable Officer.
8.4.5. Where an individual member, employee or person providing services to the Group is aware of an interest which:
a) has not been declared, either in the register or orally, they will declare this at the start of the meeting; or
b) has previously been declared, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the chair of the meeting, together with details of arrangements which have been confirmed for the management of the conflict of interests or potential conflict of interests.
8.4.6. The Chair of the meeting will then determine how this should be managed and inform the member of their decision. Where no arrangements have been confirmed, the Chair of the meeting may require the individual to withdraw from the meeting or part of it. The individual will then comply with these arrangements, which must be recorded in the minutes of the meeting.
8.4.7. Where the Chair of any meeting of the Group, including committees, sub- committees, or the Governing Body and the Governing Body’s committees and sub-committees, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the Vice Chair will act as chair for the relevant part of the meeting. Where arrangements have been confirmed for the management of the conflict of interests or potential conflicts of interests in relation to the chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the Vice Chair may require the chair to withdraw from the meeting or
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part of it. Where there is no Vice Chair, the members of the meeting will select one.
8.4.8. Any declarations of interests, and arrangements 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.
8.4.9. 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 interests or potential conflicts of interests, the Chair (or deputy) will determine whether or not the discussion can proceed.
8.4.10. In making this decision the Chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the group’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 interests, the chair of the meeting shall consult with Accountable Officer on the action to be taken.
8.4.11. These arrangements must be recorded in the minutes. This may include:
a) requiring another of the Group’s committees or sub-committees, the Group’s Governing Body or the Governing Body’s committees or sub-committees (as appropriate) which can be quorate to progress the item of business or, if this is not possible,
b) inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the Governing Body or committee / sub-committee in question) so that the Group can progress the item of business:
i) a member of the Clinical Commissioning Group who is an individual;
ii) an individual appointed by a member to act on its behalf in the dealings between it and the Clinical Commissioning Group;
iii) a member of a relevant Health and Wellbeing Board; or
iv) a member of a Governing Body of another clinical commissioning group.
8.4.12. In any transaction undertaken in support of the Clinical Commissioning Group’s exercise of its commissioning functions (including conversations between two or more individuals, e-mails, correspondence and other communications), individuals must ensure, where they are aware of an interest, that they conform to the arrangements confirmed for the management of that interest. Where an individual has not had confirmation of arrangements for managing the interest, Gloucestershire Clinical Commissioning Group’s Constitution - 49 - Version: 11. Date: September 2016
they must declare their interest at the earliest possible opportunity in the course of that transaction, and declare that interest as soon as possible thereafter. The individual must also inform either their line manager (in the case of employees), or the Accountable Officer of the transaction.
8.4.13. The Accountable Officer will take such steps as deemed appropriate, and request information deemed appropriate from individuals, to ensure that all conflicts of interest and potential conflicts of interest are declared.
8.5. Managing Conflicts of Interest: contractors and people who provide services to the group
8.5.1. Anyone seeking information in relation to a procurement, or participating in a procurement, or otherwise engaging with the Clinical Commissioning Group in relation to the potential provision of services or facilities to the Group, will be required to make a declaration of any relevant conflict / potential conflict of interest.
8.5.2. Anyone contracted to provide services or facilities directly to the Clinical Commissioning Group will be subject to the same provisions of this constitution in relation to managing conflicts of interests. This requirement will be set out in the contract for their services.
8.6. Transparency in Procuring Services
8.6.1. The Group recognises the importance of making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made. The Group will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers.
8.6.2. The Group will publish a Procurement Strategy approved by its Governing Body which will ensure that:
a) all relevant clinicians (not just members of the Group) and potential providers, together with local members of the public, are engaged in the decision-making processes used to procure services; and
b) service redesign and procurement processes are conducted in an open, transparent, non-discriminatory and fair way.
8.6.3. Copies of this Procurement Strategy will be available on the Group’s dedicated website, and will also be available on request from GCCG.
8.6.4 A register of procurement decisions will be maintained. This register will be publicly available and include: the details of the decision; who was involved in making the decision (i.e. Governing Body or Committee members and others with decision-making responsibility); and
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a summary of any conflicts of interest in relation to the decision and how this was managed by the CCG.
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9. GCCG AS AN EMPLOYER
9.1. GCCG recognises that its most valuable asset is its people. It will seek to enhance their skills and experience and is committed to their development in all ways relevant to the work of the group.
9.2. GCCG will seek to set an example of best practice as an employer and is committed to offering all staff equality of opportunity. It will ensure that its employment practices are designed to promote diversity and to treat all individuals equally.
9.3. The Group will ensure that it employs suitably qualified and experienced staff who will discharge their responsibilities in accordance with the high standards expected of staff employed by the Group. All staff will be made aware of this Constitution, the commissioning strategy and the relevant internal management and control systems which relate to their field of work.
9.4. The Group will maintain and publish policies and procedures (as appropriate) on the recruitment and remuneration of staff to ensure it can recruit, retain and develop staff of an appropriate calibre. The Group will also maintain and publish policies on all aspects of human resources management, including grievance and disciplinary matters.
9.5. The Group will ensure that its rules for recruitment and management of staff provide for the appointment and advancement on merit on the basis of equal opportunity for all applicants and staff.
9.6. The Group will ensure that employees' behaviour reflects the values, aims and principles set out above.
9.7. The Group will ensure that it complies with all aspects of employment law.
9.8. The Group will ensure that its employees have access to such expert advice and training opportunities as they may require in order to exercise their responsibilities effectively.
9.9. The Group will adopt a Code of Conduct for staff and will maintain and promote effective 'whistleblowing' procedures to ensure that concerned staff have means through which their concerns can be voiced.
9.10. Copies of this Code of Conduct, together with the other policies and procedures outlined in this chapter, will be available on the Group’s website, and will also be available on request from GCCG.
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10. TRANSPARENCY, WAYS OF WORKING AND STANDING ORDERS
10.1. General
10.1.1. The Group will publish annually a commissioning plan and an annual report, presenting the Group’s annual report to a public meeting.
10.1.2. Key communications issued by the Group, including the notices of procurements, public consultations, Governing Body meeting dates, times, venues, and certain papers will be published on the Group’s website, and will also be available on request from GCCG.
10.1.3. The Group may use other means of communication, including circulating information by post, or making information available in venues or services accessible to the public.
10.2. Standing Orders
10.2.1. This Constitution is also informed by a number of documents which provide further details on how the group will operate. They are the Group’s:
a) Standing Orders (Appendix C) – which sets out the arrangements for meetings and the appointment processes to elect the Group’s representatives and appoint to the Group’s committees, including the Governing Body;
b) Scheme of Reservation and Delegation (Appendix D) – which sets out those decisions that are reserved for the membership as a whole and those decisions that are the responsibilities of the Group’s Governing Body, the Governing Body’s committees and sub-committees, the group’s committees and sub-committees, individual members and employees;
c) Detailed Scheme of Delegation (Appendix E)(included in the ‘Supporting documents to the Constitution’ on the CCG’s website)
d) Prime Financial Policies (Appendix F) – which sets out the arrangements for managing the Group’s financial affairs. (included in the ‘Supporting documents to the Constitution’ on the CCG’s website)
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APPENDIX A DEFINITIONS OF KEY DESCRIPTIONS USED IN THIS CONSTITUTION
2006 Act National Health Service Act 2006
2012 Act Health and Social Care Act 2012 (this Act amends the 2006 Act) Accountable officer an individual, as defined under paragraph 12 of Schedule 1A of the 2006 Act (as (AO) inserted by Schedule 2 of the 2012 Act), appointed by NHS England, with responsibility for ensuring the group: complies with its obligations under: o sections 14Q and 14R of the 2006 Act (as inserted by section 26 of the 2012 Act), o sections 223H to 223J of the 2006 Act (as inserted by section 27 of the 2012 Act), o paragraphs 17 to 19 of Schedule 1A of the NHS Act 2006 (as inserted by Schedule 2 of the 2012 Act), and o any other provision of the 2006 Act (as amended by the 2012 Act) specified in a document published by NHS England for that purpose; exercises its functions in a way which provides good value for money. Area the geographical area that the Group has responsibility for, as defined in Chapter 2 of this constitution
Chair of the in line with national process, the individual appointed will act as Chair of the Governing Body Governing Body
Chief Finance Officer the qualified accountant employed by the Group with responsibility for financial (CFO) strategy, financial management and financial governance Clinical a body corporate established by NHS England in accordance with Chapter A2 of Commissioning Part 2 of the 2006 Act (as inserted by section 10 of the 2012 Act) Group Committee a committee or sub-committee created and appointed by: the membership of the Group a committee / sub-committee created by a committee created / appointed by the membership of the Group a committee / sub-committee created / appointed by the Governing Body Financial year this usually runs from 1 April to 31 March, but under paragraph 17 of Schedule 1A of the 2006 Act (inserted by Schedule 2 of the 2012 Act), it can for the purposes of audit and accounts run from when a clinical commissioning group is established until the following 31 March
GH&WB Gloucestershire Health and Wellbeing Board Governing Body the body appointed under section 14L of the NHS Act 2006 (as inserted by section 25 of the 2012 Act), 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 (as inserted by section 26 of the 2012 Act), and such generally accepted principles of good governance as are relevant to it. Governing Body member any member appointed to the Governing Body of the Group
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Group Gloucestershire Clinical Commissioning Group, whose constitution this is
Lay Member a lay member of the Governing Body, appointed by the Group. A lay member is an individual who is not a member of the Group or a healthcare professional (i.e. an individual who is a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002) or as otherwise defined in regulations Member a provider of primary medical services to a registered patient list, who is a member of this group (see tables in Chapter 3 and Appendix B) Practice an individual appointed by a practice (who is a member of the Group) to act on its representatives 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) Registers of interests registers a group is required to maintain and make publicly available under section 14O of the 2006 Act (as inserted by section 25 of the 2012 Act), of the interests of: the members of the group; the members of its governing body; the members of its committees or sub-committees and committees or sub- committees of its governing body; and its employees.
Register of members sets out the GP practices who are members of GCCG.
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APPENDIX B - LIST OF MEMBER PRACTICES
Practice Representative’s Practice Name Address (Main surgery Only) Signature & Date Signed Cheltenham Locality Berkeley Place 11 High Street, Cheltenham, Surgery Gloucestershire Corinthian Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Crescent Bakery Crescent Bakery, St Georges Place, Surgery Cheltenham Leckhampton Lloyd Davies House, 17 Moorend Park Surgery Road, Cheltenham Overton Park Overton Park Road, Cheltenham, Surgery Gloucestershire Royal Crescent 11 Royal Crescent, Cheltenham, Surgery Gloucestershire Royal Well Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Seven Posts Surgery Prestbury Road, Cheltenham, Gloucestershire Sixways Clinic London Road, Charlton Kings, Cheltenham Springbank Surgery Springbank Way, Cheltenham, Gloucestershire St Catherine's St Paul's Medical Centre, 121 Swindon Surgery Road, Cheltenham St George's Surgery St Paul's Medical Centre, 121 Swindon Road, Cheltenham Stoke Road Surgery 4 Stoke Road, Bishops Cleeve, Cheltenham The Portland St Paul's Medical Centre, 121 Swindon Practice Road, Cheltenham Underwood Surgery 139 St George's Road, Cheltenham, Gloucestershire Winchcombe Medical Greet Road, Winchcombe, Cheltenham Centre Yorkleigh Surgery 93 St George's Road, Cheltenham, Gloucestershire Forest of Dean Locality Blakeney Surgery Mill End, Blakeney, Gloucestershire
Brunston and Cinderhill, Coleford, Gloucestershire Lydbrook Practice
Coleford Health Railway Drive, Coleford, CentreFamily Gloucestershire Doctors Dockham Road Dockham Road Surgery, Cinderford,
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Practice Representative’s Practice Name Address (Main surgery Only) Signature & Date Signed Surgery Gloucestershire Drs Andrew, Yorkley Health Centre, Bailey Hill, Edwards, Hayes & Yorkley, Lydney ClearyYorkley and Bream Practice
Drybrook Surgery Drybrook, Gloucestershire
Forest Health Care The Health Centre, Dockham Road, Cinderford Lydney Practice The Health Centre, Albert Street, Lydney Mitcheldean Surgery Brook Street, Mitcheldean, Gloucestershire Newnham Surgery High Street, Newnham on Severn, Gloucestershire Severnbank Surgery Tutnalls Street, Lydney, Gloucestershire
Gloucester City Locality Barnwood Medical 51 BarnwoodAspen Centre, Horton Practice Road, Gloucester, Gloucestershire Bartongate Surgery 115 Barton Street, Gloucester, Gloucestershire Cheltenham Road 16 Cheltenham Road, Gloucester, Surgery Gloucestershire Gloucester City The Park, Gloucester, Gloucestershire Health Centre Gloucester Health Eastgate House, 121-131 Eastgate Access Centre Street, Gloucester Hadwen Medical Glevum Way Surgery, Abbeydale, Practice Gloucester Heathville Medical 5 HeathvilleAspen Centre, Horton Road, Practice Gloucester, Gloucestershire Hucclecote Surgery 5A Brookfield Road, Hucclecote, Gloucestershire Kingsholm Surgery Alvin Street, Gloucester, Gloucestershire London Road 97 LondonAspen Centre, Horton Road, Medical Practice Gloucester, Gloucestershire Longlevens Surgery 19b Church Road, Longlevens, Gloucester Partners in Health Pavilion Family Doctors, 153a Stroud Road, Gloucester Quedgeley Medical Olympus Park, Quedgeley, Gloucester Centre Rosebank Health 153b Stroud Road, Gloucester, Gloucestershire
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Practice Representative’s Practice Name Address (Main surgery Only) Signature & Date Signed Saintbridge Surgery Askwith Road, Saintbridge, Gloucestershire St. Johns 24 St Johns Avenue, Churchdown, AvenueChurchdown Gloucester, Gloucestershire Surgery The College Yard Mount Street, Westgate, Gloucester Surgery The Brockworth Abbotswood Road, Brockworth, Surgery Gloucestershire North Cotswolds Locality Chipping Campden Back Ends, Chipping Campden, Glos Surgery Cotswold Medical Moore Road, Bourton on the Water, Practice Cheltenham Mann Cottage Stow Road, Moreton in Marsh, Surgery Cheltenham Stow Surgery Well Lane, Stow on the Wold, Gloucestershire White House Surgery Stow Road, Moreton in Marsh, Gloucestershire South Cotswolds Locality The Avenue Surgery 1 The Avenue, Cirencester, Gloucestershire Hilary Cottage Keble Lawns, Fairford, Gloucestershire Surgery Lechlade Medical Oak Street, Lechlade, Gloucestershire Centre The Park Surgery Old Tetbury Road, Cirencester, Gloucestershire Phoenix Surgery 9 Chesterton Lane, Cirencester, Gloucestershire Rendcomb Surgery Rendcomb, Cirencester, Gloucestershire Romney House 41-43 Long Street, Tetbury, Gloucestershire St Peter's Road 1 St Peter's Road, Cirencester, Surgery Gloucestershire Stroud Locality Acorn Practice May Lane Surgery, Dursley, Gloucestershire Beeches Green Beeches Green, Stroud, Surgery Gloucestershire Cam andUley 42 The Street, Uley, Dursley, SurgeryFamily Gloucestershire Prcatice
Chipping Surgery Symn Lane, Wotton under Edge,
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Practice Representative’s Practice Name Address (Main surgery Only) Signature & Date Signed Gloucestershire Culverhay Surgery Wotton under Edge, Gloucestershire
Frampton Surgery Whitminster Lane Frampton on Severn, Gloucestershire Frithwood Surgery 45 Tanglewood Way, Bussage, Stroud
High Street Medical 31 High Street, Stonehouse, Centre Gloucestershire Hoyland Gyde Road, Painswick, Gloucestershire HousePainswick Surgery
Locking Hill Surgery Locking Hill, Stroud, Gloucestershire
Marybrook Medical Marybrook Street, Berkeley, Centre Gloucestershire Minchinhampton Bell Lane, Minchinhampton, Surgery Gloucestershire Prices Mill Surgery New Market Road, Nailsworth, Gloucestershire Regent Street 73 Regent Street, Stonehouse, Surgery Gloucestershire Rowcroft Medical Stroud, Gloucestershire Centre St Lukes Medical 53 Cainscross Road, Stroud, Centre Gloucestershire Stonehouse Health High Street, Stonehouse, Clinic Gloucestershire Stroud Valleys Beeches Green Health Centre, Stroud, Family Practice Gloucestershire (Staniforth) Walnut Tree Practice May Lane Surgery, Dursley, Gloucestershire Tewkesbury Locality Church Street 77 Church Street, Tewkesbury, Practice Gloucestershire Newent Family Watery Lane, Newent, Gloucestershire Practice (Holts Health Centre)
Mythe Medical Barton Road, Tewkesbury, Prcatice Gloucestershire
The Staunton and Corse, Staunton, Gloucester Corse Surgery
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APPENDIX C – STANDING ORDERS
1. STATUTORY FRAMEWORK AND STATUS
1.1. Introduction
1.1.1. The Standing Orders will regulate the proceedings of the Gloucestershire Clinical Commissioning Group (GCCG) so that the Group can fulfil its obligations, as set out largely in the 2006 Act, as amended by the 2012 Act and related regulations. They are effective from the date GCCG is established.
1.1.2. The Standing Orders, together with the Group’s Scheme of Reservation and Delegation59, provide a procedural framework within which the Group discharges its business. They set out:
a) the arrangements for conducting the business of the Group;
b) the appointment of member practice representatives;
c) the procedure to be followed at meetings of the Group, the Governing Body and any committees or sub-committees of the Group or the Governing Body;
d) the process to delegate powers; and
e) the declaration of interests and standards of conduct.
These arrangements must comply, and be consistent where applicable, with requirements set out in the 2006 Act (as amended by the 2012 Act) and related regulations and take account as appropriate60 of any relevant guidance.
1.1.3. The Standing Orders, Scheme of Reservation and Delegation (within the Standing Financial Instructions) have effect as if incorporated into the Group’s constitution. Group members, employees, members of the governing body, members of the Governing Body’s committees and sub-committees, members of the Group’s committees and sub-committees and persons working on behalf of the Group 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, scheme of reservation and delegation may be regarded as a disciplinary matter that could result in dismissal.
1.2. Schedule of matters reserved to the Clinical Commissioning Group and the Scheme of Reservation and Delegation
1.2.1. The 2006 Act (as amended by the 2012 Act) provides the Group with powers to delegate the Group’s functions and those of the Governing Body to certain
59 See Appendix D 60 Under some legislative provisions the group is obliged to have regard to particular guidance but under other circumstances guidance is issued as best practice guidance. Gloucestershire Clinical Commissioning Group’s Constitution - 60 - Version: 11. Date: September 2016
bodies (such as committees) and certain persons. The Group has decided that certain decisions may only be exercised by the Group in formal session. These decisions and also those delegated are contained in the Group’s Scheme of Reservation and Delegation (see Appendix D).
2. THE CLINICAL COMMISSIONING GROUP: COMPOSITION OF MEMBERSHIP, KEY ROLES AND APPOINTMENT PROCESS
2.1. Composition of Membership
2.1.1. Chapter 3 of the Group’s Constitution provides details of the membership of the Group (also see Appendix B).
2.2. Governing Structures
2.2.1. Chapter 6 of the Group’s Constitution provides details of the governing structure used in the Group’s decision-making processes, whilst Chapter 7 of the Constitution outlines certain key roles and responsibilities within the Group and its Governing Body, including the role of practice representatives (paragraph 7.6 of the Constitution).
2.2.2. The membership of the Governing Body shall be:
a) Chair; elected from the clinician members of the Governing Body being a GP on the Gloucestershire Performers List; b) not less than 18 further members including the following: i) Deputy Clinical Chair; ii) Accountable Officer; iii) Chief Finance Officer; iv) Seven Clinical Commissioning Leads v) A minimum of three lay representatives (one as Vice Chair); vi) Secondary Care Specialist; vii) Registered Nurse.
2.2.3. The Governing Body will function as a corporate decision-making body. Their roles as members of the Governing Body will be to consider the key strategic and managerial issues facing the Group in carrying out its statutory and other functions.
2.2.4. The Group may from time to time delegate such functions as it deems appropriate to any and/or all of the governing structures. A list of reserved and delegated functions is included in the groups Scheme of Reservation and Delegation (See Appendix D)
2.3. Key Roles
2.3.1. Paragraph 6.6.4 of the Group’s Constitution sets out the composition of the Group’s Governing Body whilst Chapter 7 of the Group’s Constitution identifies Gloucestershire Clinical Commissioning Group’s Constitution - 61 - Version: 11. Date: September 2016
certain key roles and responsibilities within the Group and its Governing Body. These Standing Orders set out how the Group appoints individuals to these key roles.
2.3.2. The Accountable Officer, as described in paragraph 7.12 of the group’s constitution, is subject to the following appointment process:
a) Nominations – subject to the national process as identified by NHS England. All GPs in member practices have the opportunity to apply.
b) Eligibility – compliance with criteria for each post and through sponsorship of GCCG and subject to the provisions of paragraph 6.6.3 of this constitution
c) Appointment process – national process as identified by NHS England;
d) Grounds for removal from office – subject to the Code of Conduct: code of accountability in the NHS publication or any superseding publication;61
e) Notice period – 6 months.
2.3.3. The Clinical Chair, as described in paragraphs 6.6.7 and 7.10 of the Group’s Constitution, is subject to the following appointment process:
a) Nominations – subject to the national process as identified by NHS England. All Only GPs clinicians working regularly in Gloucestershire member practices have the opportunityare eligible to apply;
b) Eligibility – compliance with the criteria for the post and through sponsorship of CCG and subject to the provisions of paragraph 6.6.3 of this constitution, as well as in line with the national guidance;
c) Appointment process – national process as identified by NHS England;
d) Term of office – 4 years;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this constitution pertaining to eligibility to serve on the Governing Body or following a vote of no confidence taken by two thirds or more of the GP Governing Body members Member Practice Council at a properly constituted meeting called in line with the provisions of this Constitution ;
g) Notice period – 36 months.
2.3.4. The Deputy Clinical Chair, as listed in paragraphs 6.6.7 and 7.11 of the Group’s Constitution, is subject to the following appointment process:
61 Code of Conduct: code of accountability in the NHS published by the DH NHS Appointments Commission Gloucestershire Clinical Commissioning Group’s Constitution - 62 - Version: 11. Date: September 2016
a) Nominations – sponsorship through CCG subject to the national process as identified by NHS England. Only clinicians working regularly in Gloucestershire member practices are eligible to apply;
b) Eligibility – sponsorship through CCG and subject to the provisions of paragraph 6.6.3 of this constitution;
c) Appointment process – sponsorship through CCG;
d) Term of office – 4 years;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this constitution pertaining to eligibility to serve on the Governing Body or following a vote of no confidence taken by two thirds or more of the GP Governing Body members Member Practice Council at a properly constituted meeting called in line with the provisions of this constitution ;
g) Notice period – 36 months.
2.3.5. The Chief Finance Officer (CFO), as listed in paragraph 7.13 of the Group’s Constitution, is subject to the following appointment process:
a) Nominations – subject to the national process as identified by NHS England;
b) Eligibility - sponsorship through CCG/NHS and subject to the provisions of paragraph 6.6.3 of this constitution;
c) Appointment process – national process as identified by NHS England;
d) Eligibility for reappointment – subject to national guidance;
e) Grounds for removal from office – subject to the Code of Conduct: code of accountability in the NHS publication or any superseding publication f) Notice period – 63 months.
2.3.6. The Locality Clinical Commissioning Leads, as listed in paragraph 6.6.8 and 7.5 of the Group’s Constitution, are subject to the following appointment process:
a) Nominations – local election process carried out in conjunction with the LMC. Only clinicians working regularly in Gloucestershire member practices are eligible to apply;
b) Eligibility –subject to the provisions of paragraph 6.6.3 of this Constitution;
c) Appointment process – local election process carried out in conjunction with the LMC; Gloucestershire Clinical Commissioning Group’s Constitution - 63 - Version: 11. Date: September 2016
d) Term of office – subject to national guidance;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this Constitution pertaining to eligibility to serve on the Governing Body or following a vote of no confidence taken by two thirds or more of the Member Practice Council at a properly constituted meeting called in line with the provisions of this Constitution;
g) Notice period – 3 months.
2.3.7. The Lay Members, as listed in paragraphs 6.6.9 and 7.14 of the Group’s Constitution, is subject to the following appointment process:
a) Nominations – local process based on national guidance;
b) Eligibility – subject to the provisions of paragraph 6.6.3 of this Constitution;
c) Appointment process – national process;
d) Term of office – subject to national guidance;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this Constitution;
g) Notice period –3 months.
2.3.8. The Registered Nurse Representative, as listed in paragraphs 6.6.11 and 7.15 of the Group’s Constitution, is subject to the following appointment process:
a) Nominations – local process;
b) Eligibility –subject to the provisions of paragraph 6.6.3 of this Constitution;
c) Appointment process – appointment by Chair of CCG following nomination;
d) Term of office – subject to national guidance;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this Constitution;
g) Notice period –3 months. Gloucestershire Clinical Commissioning Group’s Constitution - 64 - Version: 11. Date: September 2016
2.3.9. The Secondary Care Specialist, as listed in paragraphs 6.6.12 and 7.16 of the group’s constitution, is subject to the following appointment process:
a) Nominations – subject to local process, ensuring there are no conflicts of interest in relation to CCG commissioning responsibilities;
b) Eligibility –subject to the provisions of paragraph 6.6.3 of this constitution;
c) Appointment process – appointment by Chair of CCG following nomination;
d) Term of office – subject to national guidance;
e) Eligibility for reappointment – subject to national guidance;
f) Grounds for removal from office – subject to the provisions of paragraph 6.6.3 of this constitution;
g) Notice period –3 months.
2.3.10. The roles and responsibilities of each of these key roles are described in paragraph 6.6. and Chapter 7 of the Group’s Constitution.
3. MEETINGS OF THE CLINICAL COMMISSIONING GROUP
3.1. Calling meetings
3.1.1. Ordinary meetings of the Group shall be held at regular intervals at such times and places as the Group may determine and not less than annually.
3.1.2. The Chair of the Group may call a meeting at any time.
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 Associate Director Corporate Governance at least 10 working days (i.e. excluding weekends and bank holidays) before the meeting takes place.
3.2.2. The request should state whether the business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than ten working days before a meeting may be included on the agenda at the discretion of the Chair.
3.2.3. Supporting papers for such items need to be submitted at least 10 working days before the meeting takes place. The agenda and supporting papers will be
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circulated to all members of a meeting at least 5 working days before the date the meeting will take place.
3.2.4. The Group may determine that certain matters will appear on every agenda for a meeting and shall be addressed prior to any other business being conducted. The Group may also determine that all papers presented should be in a prescribed format. However, the Chair may waive this requirement if, in their opinion, urgency requires that a paper be presented in another format.
3.2.5. Agendas and certain papers for the Group’s Governing Body – including details about meeting dates, times and venues - will be published on the Group’s website, and will also be available on request from GCCG.
3.3. Petitions
3.3.1. Where a petition compiled by practice members has been received by the Group, the chair of the Governing Body shall include the petition as an item for the agenda of the next meeting of the Governing Body.
3.4. Chair of a meeting
3.4.1. At any meeting of the Group or its Governing Body or of a committee or sub- committee, the chair of the Group, Governing Body, committee or sub- committee, if any and if present, shall preside. If the chair is absent from the meeting, the Vice 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 Vice Chair, if present, shall preside. If both the chair and Vice Chair are absent, or are disqualified from participating, or there is neither a chair or deputy, a member of the Group, 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 Chair of the Governing Body 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
3.6.1 A quorum will be reached when at least seven members of the Governing Body are present. The attendees should include specifically:- . the Chair, Deputy Clinical Chair or Vice Chair; . the Accountable Officer (or deputy); . the Chief Finance Officer (or deputy); . One Lay Member . Three GP/OHP Clinical Commissioning Leads acting on behalf of member practices. Gloucestershire Clinical Commissioning Group’s Constitution - 66 - Version: 11. Date: September 2016
3.6.2 If the Chair or a member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest that person shall no longer count towards quorum. If a quorum is then not available for discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.
3.6.3 Where the Governing Body is making a decision in which all GP members have an interest, these members will required to leave the meeting. In this situation, the meeting will be quorate if the following are present:
. the Vice Chair; . the Accountable Officer (or deputy); . the Chief Finance Officer (or deputy); . two Executive Directors . one Lay Member, in addition to the Vice Chair . the Registered Nurse or Secondary Care Specialist
3.6.4 The Accountable Officer (or deputy) will reserve the right to refer a decision to the Governing Body should an item or issue arise where it is judged that approval would secure essential corporate governance.
3.6.5 For all other of the Group’s committees and sub-committees, including the Governing Body’s committees and sub-committees, the details of the quorum for these meetings and status of representatives are set out in the appropriate terms of reference.
3.7 Decision making
3.7.1 Chapter 6 of the Group’s Constitution, together with the Scheme of Reservation and Delegation, sets out the governing structure for the exercise of the Group’s statutory functions. Generally it is expected that decision making at meetings will be by consensus of members. Should this not be possible then a vote of members will be required, the process for which is set out below:
3.7.2 For votes at meetings of the Governing Body:
Eligibility – only designated members of the Governing Body are allowed to vote.
Voting Process - At the discretion of the Chair all questions put to the vote shall be determined by oral expression or by a show of hands, unless the Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot;
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Majority necessary to confirm a decision – 75% of members required to make a decision;
Casting vote – In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second and casting vote;
Dissenting views – A motion may be proposed by the Chair of the meeting or any member present. It must also be seconded by another member.
3.7.3 Should a vote of the Governing Body be taken, the outcome of the vote, and any dissenting views, must be recorded in the minutes of the meeting.
3.7.4 For all other meetings of the Group’s committees and sub-committees, including the Governing Body’s committees and sub-committees, the process for holding a vote is set out in the appropriate terms of reference.
3.8 Emergency powers and urgent decisions
3.8.1 The Chair of GCCG may call a meeting of the Governing Body at any time.
3.8.2 Once fully authorised the powers which GCCG has reserved to itself may, in an emergency or where an important decision must be made urgently, be exercised by the Chair or Vice Chair together with the Accountable Officer after having consulted at least two non-officer members. The exercise of such powers by the Chair (or Vice Chair) and Accountable Officer shall be reported to the next formal meeting of GCCG in public session for ratification. In the interim, the power remains with the Chair and the Accountable Officer.
3.8.3 One third or more of the member practices of GCCG may requisition a meeting in writing. If the Chair refuses, or fails, to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting.
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 at least two thirds of those members present at the meeting of the Governing Body signify their agreement to suspension.
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.
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3.9.4 No formal business shall be transacted while the Standing Orders are suspended and the decision to do so shall be considered by the Audit Committee
3.10 Variation and amendment of Standing Orders
3.10.1 Standing Orders can be varied in the following situations: a) upon a recommendation of the Chair and/or Accountable Officer included on the agenda for the meeting; b) two-thirds of the members are present at the meeting where the variation or amendment is being discussed and that at least half of the members vote in favour of the amendment; c) providing that any variation or amendment does not contravene a statutory provision, direction made by the Secretary of State or guidance issued by NHS England.
3.11 Record of Attendance
3.11.1 The names of all members of the meeting present at the meeting shall be recorded in the minutes of the Group’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 / sub-committees present shall be recorded in the minutes of the respective Governing Body committee / sub-committee meetings.
3.12 Minutes
3.12.1 The minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where they shall be signed by the person presiding at it.
3.12.2 The minutes will be formally signed off by the Chair of the meeting and (where appropriate) will be made available to attendees and members of the public.
3.13 Admission of public and the press
3.13.1 The Group will hold meetings in public on a regular basis at such times and places as the Governing Body may determine. Members of the public and representatives of the press may attend all meetings of Governing Body.
3.13.2 The public and representatives of the press, shall be required to withdraw upon the Governing Body resolving as follows:
“that representatives of the press and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”
Section 1(2), Public Bodies (Admissions to Meetings) Act 1960. Gloucestershire Clinical Commissioning Group’s Constitution - 69 - Version: 11. Date: September 2016
3.13.3 The above resolution shall be taken in public and there shall be a public statement, either on the agenda or made by the Chair of the meeting, setting out in broad terms the nature of the business to be discussed (which does not breach the confidentiality of the subject matter).
3.13.4 Matters to be dealt with by GCCG following the exclusion of representatives of the press, and other members of the public shall be referred to as “Part II meeting”) and shall be confidential to the members of GCCG.
3.13.5 Members and officers or any employee of GCCG in attendance shall not reveal or disclose the contents of papers or minutes from a Part II meeting outside of GCCG, without the express permission of the Accountable Officer or Chair. This prohibition shall apply equally to the content of any discussion during the Part II meeting which may take place on such reports or papers.
4 APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES
4.1 Appointment of committees and sub-committees
4.1.1 The Group may appoint committees and sub-committees of the Group, subject to any regulations made by the Secretary of State62, and also make provision for the appointment of committees and sub-committees of its Governing Body. Where such committees and sub-committees of the Group, or committees and sub-committees of its Governing Body, are appointed they are included in Chapter 6 of the Group’s Constitution.
4.1.2 Other than where there are statutory requirements, such as in relation to the Governing Body’s Audit Committee or Remuneration Committee, the Group 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 Group.
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 any other committees and sub-committees of the Group 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 and are set out in Appendices to the Constitution.
4.3 Delegation of Powers by Committees to Sub-committees
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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 Group.
4.4 Approval of Appointments to Committees and Sub-Committees
4.4.1 The Group shall approve the appointments to each of the committees and sub- committees which it has formally constituted including those of the Governing Body. Where the Group determines that persons, who are neither members nor employees, shall be appointed to a committee or sub-committee the terms of such appointment shall be within the powers of the Group. The Group shall define the powers of such appointees and shall agree such travelling or other allowances as it considers appropriate.
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 Group 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 Group may have a seal for executing documents where necessary. The following individuals or officers are authorised to authenticate its use by their signature:
a) the Accountable Officer;
b) the Chair of the Governing Body;
c) the Chief Finance Officer.
6.2 Execution of a document by signature
6.2.1 The following individuals are authorised to execute a document on behalf of the group by their signature.
a) the Accountable Officer;
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b) the Chair of the Governing Body;
c) the Chief Finance Officer.
7 OVERLAP WITH OTHER CLINICAL COMMISSIONING GROUP POLICY STATEMENTS / PROCEDURES AND REGULATIONS
7.1 Policy statements: general principles
7.1.1 The Group will from time to time agree and approve policy statements / procedures which will apply to all or specific groups of staff employed by Gloucestershire 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 Group’s Standing Orders.
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APPENDIX D – SCHEME OF RESERVATION & DELEGATION
1. SCHEDULE OF MATTERS RESERVED TO THE CLINICAL COMMISSIONING GROUP AND SCHEME OF DELEGATION
1.1. The arrangements made by the Group as set out in this scheme of reservation and delegation of decisions shall have effect as if incorporated in the Group’s Constitution.
1.2. GCCG remains accountable for all of its functions, including those that it has delegated.
1.3 The paragraphs below indicate GCCG has reserved and delegated decisions.
1.3.1 Regulation and Control
GCCG will:
. Make arrangements by which the members of GCCG approve the decisions that are reserved for the membership.
. Approve applications to NHS England on any matter concerning changes to the GCCG Constitution, including terms of reference for the Group’s Governing Body, its committees, membership of committees, the overarching Scheme of Reservation and Delegated Powers, arrangements for taking urgent decisions and, Sstanding Oorders and Prime Financial Policies.
. Exercise or delegate GCCG functions which have not been retained as reserved by the Group, delegated to the Governing Body, delegated to a committee or sub-committee of the Group or to one of its members or employees.
. Prepare GCCG’s overarching Scheme of Reservation and Delegation, which sets out those decisions of the Group reserved to the membership and those delegated to the:
o Group’s Governing Body; o committees and sub-committees of the Group; or o the Group’s members or employees,
and sets out those decisions of the Governing Body reserved to the Governing Body and those delegated to the:
o Governing Body’s committees and sub-committees; o members of the Governing Body; o an individual who is member of the Group but not the Governing Body or a specified person;
for inclusion in the GCCG Constitution. Gloucestershire Clinical Commissioning Group’s Constitution - 73 - Version: 11. Date: September 2016
. Approve the GCCG overarching Scheme of Reservation and Delegation.
. Prepare GCCG operational scheme of delegation, which sets out those key operational decisions delegated to individual employees of GCCG, not for inclusion in the Group’s Constitution.
. Approve GCCG’s operational scheme of delegation that underpins the Group’s ‘overarching Scheme of Reservation and Delegation’ as set out in its Constitution.
. Prepare detailed financial policies that underpin the GCCG Prime Financial Policies.
. Approve detailed financial policies.
. Approve arrangements for managing exceptional funding requests.
. Set out who can execute a document by signature / use of the seal.
1.3.2 Practice Member Representatives and Members of the Governing Body
Responsibilities of member practices to GCCG will include:
. Actively engage with GCCG to help improve services within the area. . Share all appropriate information and data to support delivery of referral and other prescribing and emergency admissions data. . Through a Clinical Programme Group approach, follow the clinical pathways and referral protocols agreed by GCCG (except in individual cases where there are justified clinical reasons for not doing this) which are fed back appropriately. . Manage the practice’s prescribing budget within allocated resource. . Participate in and deliver, as far as possible, the clinical, quality, safety and cost effective strategies agreed by GCCG and GH&WB. . Establish a practice reference group as a means of obtaining the views and experiences of patients and carers. . Work constructively with the locality sub-committee/GCCG. . Respond in a timely manner to reasonable information requests from GCCG. . Approve the appointment of governing body members, the process for recruiting and removing non-elected members to the Governing Body (subject to any regulatory requirements) and succession planning. . Approve arrangements for identifying the group’s proposed Accountable Officer.
1.3.3 Strategy and Planning
GCCG will:
. Agree the vision, values and overall strategic direction of GCCG. . Approve GCCG operating structure. . Approve GCCG commissioning plan.
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. Approve GCCG corporate budgets that meet the financial duties as set out in paragraph 5.3 of the main body of the Constitution. . Approve variations to the approved budget where variation would have a significant impact on the overall approved levels of income and expenditure or the group’s ability to achieve its agreed strategic aims.
1.3.4 Annual Reports and Accounts
GCCG will:
. Approve GCCG annual report and annual accounts. . Approve arrangements for discharging GCCG statutory financial duties.
1.3.5 Human Resources
GCCG will:
. Approve the terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities. . Approve terms and conditions of employment for all employees of GCCG including, pensions, remuneration, fees and travelling or other allowances payable to employees and to other persons providing services to the group. . Approve any other terms and conditions of services for GCCG’s employees. . Determine the terms and conditions of employment for all employees of the Group. . Determine pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group. . Recommend pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group. . Approve disciplinary arrangements for employees, including the Accountable Officer (where he/she is an employee or member of the clinical commissioning group) and for other persons working on behalf of the Group. . Review disciplinary arrangements where the Accountable Officer is an employee or member of another clinical commissioning group . Approval of the arrangements for discharging GCCG’s statutory duties as an employer. . Approve human resources policies for employees and for other persons working on behalf of GCCG.
1.3.6 Quality and Safety
GCCG will:
. Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to secure continuous improvement in quality and patient outcomes. . Approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services.
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1.3.7 Operational and Risk Management
GCCG will:
. Prepare and recommend an operational scheme of delegation that sets out who has responsibility for operational decisions within GCCG. . Approve GCCG’s counter fraud and security management arrangements. . Approve the Group’s risk management arrangements. . Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006). . Approve a comprehensive system of internal control, including budgetary control, that underpin the effective, efficient and economic operation of GCCG. . Approve proposals for action on litigation against or on behalf of GCCG. . Approve GCCG arrangements for business continuity and emergency planning.
1.3.8 Information Governance
GCCG will:
. Approve GCCG’s arrangements for handling complaints. . Approve arrangements for ensuring appropriate confidentiality in relation to GCCG’s records, including patients’ medical records, and for the secure storage, management and transfer of information and data.
1.3.9 Tendering and Contracting
GCCG will:
. Approve GCCG contracts for any commissioning support. . Approve GCCG contracts for corporate support (for example finance provision).
1.3.10 Partnership Working
GCCG will:
. Approve decisions that individual members or employees of CCG participating in joint arrangements on behalf of the Group can make. Such delegated decisions must be disclosed in this scheme of reservation and delegation. . Approve decisions delegated to joint committees established under section 75 of the 2006 Act.
1.3.11 Commissioning and Contracting for Clinical Services
GCCG will:
. Approve arrangements for discharging GCCG’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement Gloucestershire Clinical Commissioning Group’s Constitution - 76 - Version: 11. Date: September 2016
in the quality of services, obtaining appropriate advice and public engagement and consultation. . Approve arrangements for co-ordinating the commissioning of services with other groups and or with the local authority(ies), where appropriate
1.3.12 Communications
The GCCG, through the Integrated Governance and Quality Committee will:
. Approve arrangements for handling Freedom of Information requests. . Determine arrangements for handling Freedom of Information requests.
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Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body REGULATION AND CONTROL Determine the arrangements by which the members of the Group approve those
decisions that are reserved for the membership. Consideration and approval of applications to NHS England on any matter concerning changes to the Group’s Constitution, including terms of reference for the Group’s Governing Body, its committees, membership
of committees, the overarching Scheme of Reservation and Delegated powers, arrangements for taking urgent decisions and, Standing Orders and Prime Financial Policies. Exercise or delegation of those functions of the Clinical Commissioning Group which have not been retained as reserved by the
Group, delegated to the Governing Body or other committee or sub-committee or [specified] member or employee. Require and receive the declaration of interests from members of the Governing Body. Require and receive the declaration of interests from members, practice representatives and employees of the Group. Approve arrangements for dealing with
Complaints. Adopt the organisation structures, processes and procedures to facilitate the discharge by the Group of its statutory and
Gloucestershire Clinical Commissioning Group’s Constitution - 78 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body other functions and to agree modifications thereto. Receive reports from committees that the Group is required by statute or other
regulation to establish and to take action upon those reports as necessary. Confirm the recommendations of the Group’s committees where the committees do not have executive powers. Approve arrangements relating to the discharge of the Group’s responsibilities as a corporate trustee for funds held on trust. Note Approve the terms of reference of sub- committees established by committees of the Group and/or Governing Body. Manage members of the Group, practice representatives, members of the Governing Body or employees who are in breach of
statutory requirements or the Group’s Standing Orders or Standards of Business Conduct Policy. Approve any urgent decisions taken by the Chair of the Governing Body and the
Accountable Officer for ratification by the Group in public session. Ratify or otherwise instances of failure to comply with the Standing Orders brought to the attention of the Accountable Officer. Such failures to be reported to the Group in formal session. Approve procedure for the declaration of
hospitality and/or hospitality received. Gloucestershire Clinical Commissioning Group’s Constitution - 79 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body
PRACTICE MEMBER REPRESENTATIVES AND MEMBERS OF THE GOVERNING BODY Appoint and remove practice representatives. Member Practice Appoint the Chair of the Governing Body. Remove the Chair of the Governing Body in
advance of their term of office expiring. Appoint the Deputy Chair(s) of the
Governing Body. Remove the Deputy Chair(s) of the Governing Body in advance of their term of office expiring. Appoint and dismiss other committees (and individual members) that are directly accountable to the Governing Body. Appoint, appraise, discipline and dismiss
employee members of the Governing Body. Confirm the appointment of members of any committee of the Group as representatives of the Group on outside bodies. Note the proposals of the Remuneration Committee and to note the proposals of the
Accountable Officer for those staff not considered by the Remuneration Committee STRATEGY AND PLANNING
Gloucestershire Clinical Commissioning Group’s Constitution - 80 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body Define the strategic aims and objectives of the Group.
Identify key strategic risks, evaluate them and ensure adequate responses are in place and are monitored. Approve plans in respect of the application of available financial resource to support the agreed local commissioning priorities. Approve proposals for ensuring quality and developing clinical governance in services provided by the groups contractors having regard to any guidance issued by NHS England. Approve the Group’s annual commissioning
strategy and plan. Approve outline and final business cases for capital investment if this represents a variation from the strategic plan. Approve all budgets of the Group. Approve annually the organisational
development proposals of the Group. Ratify the Governing Body’s proposals for
the development of the Group. Ratify proposals for the acquisition, disposal
or change of use of real property. Approve banking arrangements.
Gloucestershire Clinical Commissioning Group’s Constitution - 81 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body Approve proposals in individual cases for the write off of losses or making special payments above the limits of delegation to the Accountable Officer and Chief Finance Audit Committee Officer (for losses and special payments). Approve individual compensation payments. Approve the Group’s strategies as recommended by committees or the employee members of the Governing Body. Ratify the Group’s strategies as
recommended by the Governing Body. Note the Group’s corporate and clinical policies as advised by committees with delegated powers of approval as contained in their terms of reference to approve policies on behalf of the Governing Body. Approve Group policies as defined for
Governing Body approval. Note Group policies as approved by the
Governing Body and/or its committees. ANNUAL REPORTS AND ACCOUNTS Ratify the appointment (and where necessary dismissal) of External Auditors including arrangements for the separate audit of funds
held on trust, following consideration of the advice of the Auditor Panel, where appropriate. Receive the annual management letter received from the External Auditor, taking account of the advice, where appropriate, of
Gloucestershire Clinical Commissioning Group’s Constitution - 82 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body the Audit Committee. Receive an annual report from the Internal Auditor and agree action on
recommendations where appropriate of the Audit Committee. Receipt and approval of the Group’s Annual
Report and Accounts. Receipt and approval of the Annual Report
and Accounts for funds held on trust, if any. Receipt of such reports as the Governing Body sees fit from its committees and/or
other committees of the Group in respect of their exercise of powers delegated to them. HUMAN RESOURCES Approve the terms and conditions, remuneration and travelling and other
allowances for members of the Governing Remuneration Body, including pensions and gratuities. Committee Approve terms and conditions of employment for all employees of the Group, including, pensions, remuneration, fees and
travelling or other allowances payable to Remuneration employees and to other persons providing Committee services to the Group. Approve any other terms and conditions of service for the Group’s employees.
Remuneration Committee Determine the terms and conditions of employment for all employees of the Group. Remuneration Gloucestershire Clinical Commissioning Group’s Constitution - 83 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body Committee Determine pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the
Group. Remuneration Committee
Recommend pensions, remuneration, fees and allowances payable to employees and
to other persons providing services to the Remuneration Group. Committee Approve disciplinary arrangements for employees, including the Accountable Officer (where they are an employee and/or
member of the Clinical Commissioning Remuneration Group) and for other persons working on Committee behalf of the Group. Review disciplinary arrangements where the Accountable Officer is an employee or
member of another clinical commissioning Remuneration Group. Committee Approval of the arrangements for discharging the Group’s statutory duties as an employer.
Remuneration Committee Approve human resources policies for employees and for other persons working on behalf of the Group. Integrated Governance and Quality Committee QUALITY AND SAFETY
Gloucestershire Clinical Commissioning Group’s Constitution - 84 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to secure continuous Integrated improvement in quality and patient Governance and outcomes. Quality Committee Approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services. OPERATIONAL AND RISK MANAGEMENT Prepare and recommend an operational scheme of delegation that sets out who has
responsibility for operational decisions within the Group. Approve the Group’s counter fraud and security management arrangements. Audit Committee Approve the Group’s risk management arrangements. Integrated Governance and Quality Committee Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds
with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006). Approval of a comprehensive system of internal control, including budgetary control, that underpin the effective, efficient and Audit Committee
Gloucestershire Clinical Commissioning Group’s Constitution - 85 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body economic operation of the Group. Approve proposals for action on litigation against or on behalf of the Clinical Commissioning Group. Approve the Group’s arrangements for business continuity and emergency planning.
INFORMATION GOVERNANCE Approve the Group’s arrangements for handling complaints. Integrated Governance and Quality Committee Approval of the arrangements for ensuring appropriate and safekeeping and confidentiality of records and for the Integrated storage, management and transfer of Governance and information and data. Quality Committee TENDERING AND CONTRACTING Approval of the Group’s contracts for any
commissioning support. Approval of the Group’s contracts for corporate support (for example finance provision). PARTNERSHIP WORKING Approve decisions that individual members
or employees of the Group participating in
Gloucestershire Clinical Commissioning Group’s Constitution - 86 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body joint arrangements on behalf of the Group can make. Such delegated decisions must be disclosed in this Scheme of Reservation and Delegation. Approve decisions delegated to joint committees established under section 75 of the 2006 Act.
COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES Approval of the arrangements for discharging the Group’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, Integrated reducing inequalities, improvement in the Governance and quality of services, obtaining appropriate Quality Committee advice and public engagement and consultation. Approve arrangements for co-ordinating the commissioning of services with other groups
and or with the local authority(ies), where appropriate. Approve recommendations made by the Primary Care Commissioning Committee for the following primary care services: a. Primary medical care strategy for Gloucestershire;
Gloucestershire Clinical Commissioning Group’s Constitution - 87 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body b. Planning primary medical care services in Gloucestershire (including needs assessment); c. Primary Care Estates Strategy; d. Premises improvement grants and capital Primary Care Commissioning developments; Committee e. Contractual action such as issuing (paras c to f) branch/remedial notices, and removing a contract;
f. Practice mergers
Procurement of primary care services under co-commissioning arrangements:
a. The award of GMS, PMS and APMS contracts. This includes: the design of PMS and APMS contracts; and monitoring of contracts; Primary Care b. Locally defined and designed enhanced Commissioning services (“Local Enhanced Services” and Committee “Directed Enhanced Services”);
c. Making decision regarding local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);
Gloucestershire Clinical Commissioning Group’s Constitution - 88 - Version: 11. Date: September 2016
Reserved or Reserved to the Accountable Chief Finance Policy Area Decision delegated to Other (stated) Membership Officer Officer Governing Body d. Procurement of new practice provision;
e. Discretionary payment (e.g., returner/retainer schemes);
COMMUNICATIONS Approving arrangements for handling Freedom of Information requests. Integrated Governance and Quality Committee Determining arrangements for handling Freedom of Information requests. Integrated Governance and Quality Committee
Gloucestershire Clinical Commissioning Group’s Constitution - 89 - Version: 11. Date: September 2016
APPENDIX E – DETAILED SCHEME OF DELEGATION
The Detailed Delegated Limits outlined below represent the lowest level to which authority within the CCG is delegated
Delegation to lower levels or other offices is not permitted without the specific authority of in writing of the Accountable Officer or the Chief Finance Officer. All items concerning Finance must be carried out in accordance with Prime Financial Polices and Standing Orders.
Delegated authority may be exercised by a formally nominated deputy in the absence of the primary delegate.
In certain circumstances the limits of authorisation in this document may be temporarily amended. Such amendments will be communicated by the Accountable Officer or Chief Finance Officer using cascade e‐mails.
Gloucestershire Clinical Commissioning Group’s Constitution - 90 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 1. Management of Budgets ‐ Sec 7 Responsibility to keep expenditure within budgets and to ensure that budgets are only used for the type of expenditure for which they have been set.
At individual budget level (Pay and Non Budget Holder Pay)
At Directorate level Director
All Other Areas Chief Finance Officer/Accountable Officer
Prime Financial Policies 2. Maintenance/Operation of Bank Chief Finance Officer In accordance with PFP ‐ Sec 11 Accounts
a) Approval of banking arrangements
Gloucestershire Clinical Commissioning Group’s Constitution - 91 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
b) Variation to approved signatories Governing Body
Chief Finance Officer
Prime Financial Policies 3. Non Pay Revenue and Capital ‐ Sec 17 Expenditure / Requisitioning / Ordering
a) Payment of Goods and Services Stock/non‐stock requisitions up to £1,000 Budget Manager
Stock/non‐stock requisitions up to Budget Holder £10,000
Stock/non stock requisitions up to Directors £249,999
Stock/non stock requisitions from Chief Finance Officer £250,000 to £499,999
Gloucestershire Clinical Commissioning Group’s Constitution - 92 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
Stock/non stock requisitions from Accountable Officer £500,000 to £999,999
Stock/non stock requisitions from Governing Body £1,000,000
b) Authorisation of Payments against an Accountable Officer Chief signed NHS Contract or signed s75 or Finance Officer, s256 with the Local Authority Director, Deputy Director of Commissioning, Deputy CFO Prime Financial Policies f) Approval of Virements ‐ Sec 7 Between commissioning budgets up to Budget Holder £50,000 or between admin budgets/provider patient services non‐ recurrently up to £10,000
Between commissioning budgets up to Chief Finance Officer £100,000 or between admin budgets recurrently and/or up to £50,000
Gloucestershire Clinical Commissioning Group’s Constitution - 93 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Above £100,000 between Accountable Officer commissioning budgets or above £50,000 between admin budgets
g) Orders exceeding 36 month period Accountable Officer or Chief Finance Officer
h) All contracts for Non Health Care As section 3a goods & services and subsequent variations to contracts i) Prepayments over £1,500 Chief Finance Officer or Deputy CFO
Prime Financial Policies 4. Capital Schemes ‐ Sec 18 a) Delegated Limits for Capital Investment for buildings, PFI, IM&T and equipment investments, and property leases
Up to £35 million NHS England – subject to full business case approval
Gloucestershire Clinical Commissioning Group’s Constitution - 94 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner and following approval by Governing Body From £35 million and above Department of Health and HM Treasury Selection of Architects, quantity Accountable Officer or surveyors, consultant engineer and Chief Finance Officer other professional advisors within EU regulations
Financial monitoring and reporting Chief Finance Officer on all capital scheme expenditure Prime Financial 5.1 Quotation, Tender and & Contract Policies - Sec 13 Procedures (including secondary, primary and community healthcare services) where no suitable nationally negotiated framework agreements / contracts are available for use:
(Values are the total value of expenditure
excluding VAT for the total duration of
any time period committed to):
Gloucestershire Clinical Commissioning Group’s Constitution - 95 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
a) No requirement to obtain As per section 3 quotes for single items up to £1,000 As per section 3 b) 2 written quotes for goods / services between £1,000 and
£5,000.
As per section 3
c) Obtaining a minimum of 3 written quotations for goods / services from £5,000 to £50,000 As per section 3 d) Obtaining a minimum of 3 written competitive tenders for goods / services from £50,000 (process by delegated procurement personnel). Chief Finance Officer / e) Contracts above European Deputy CFO Union (OJEU) limits. Chief Finance Officer/
Gloucestershire Clinical Commissioning Group’s Constitution - 96 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner f) Approval to accept quote / Accountable Officer Report to Audit tender other than the lowest that Committee meet the award criteria Quotations & tenders <£99,999
Chief Finance Tenders >£100,000 Officer/Accountable Officer
g) Waiving of quotations & Tenders subject to SOs & PFP Chief Finance Officer Up to £99,999 Accountable Officer £100,000 ‐ £249,999 Governing Body £250,000+ Directors and Senior Opening Quotations: Manager
Accountable Officer and
Gloucestershire Clinical Commissioning Group’s Constitution - 97 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Opening Tenders: Directors, Deputy CFO, Associate Director of Corporate Governance
5.2. A Mini‐Competition* or Direct Call‐ Off* for goods or services of any value (including secondary, primary and community healthcare services) against a suitable nationally negotiated framework agreements / contracts:
*In accordance with framework terms and conditions of contract.
Up to £1,000 As per section 3
Between £1,000 and £5,000 As per section 3
From £50,000 As per section 3 Report to Audit Committee
Gloucestershire Clinical Commissioning Group’s Constitution - 98 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 6. Setting of Fees and Charges ‐ Sec 12 a) Private Patient, Overseas Visitors, Chief Finance Officer or Income Generation and other Deputy CFO patient related services
b) Price of NHS Contracts Chief Finance Officer or Deputy CFO
c) Price of Non NHS Contracts Chief Finance Officer or Deputy CFO 7. Income Collection
Cancellation of invoices incorrectly Chief Finance Officer or raised Deputy CFO Authority to pursue legal action for Chief Finance Officer or bad debts Deputy CFO Approval of write offs relating to over Chief Finance Officer payment of salary
Gloucestershire Clinical Commissioning Group’s Constitution - 99 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 8. Agreement and Signing of Contracts ‐ Sec 14 for the purchasing of Health Care and Agreements with the Local Authority and GP Practices
Signing of Health Care Contracts with the Local Authority Director of Commissioning Contracts of less than £10,000,000 Implementation or Chief Finance Officer
Accountable Officer or Contracts greater than Chief Finance Officer £10,000,000
Director of Commissioning Variations to contracts Implementation or Chief Finance Officer
Accountable Officer / Signing of Agreements between the CCG Chief Finance Officer or and the Local Authority Director of Commissioning
Gloucestershire Clinical Commissioning Group’s Constitution - 100 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Implementation
Signing of Agreements and Contracts for Accountable Officer or the purchase of primary care services Chief Finance Officer with GP practices.
Prime Financial Policies 9. Engagement of Staff Not On the ‐ Sec 7 Establishment
a) Non Medical Consultancy Staff Accountable Officer and or total commitment is Chief Finance Officer <£20,000 in one year where budget is available >£20,000 or where no budget available
b) Engagement of CCG’s Solicitors Associate Director of Corporate Governance
c) Booking of Bank or Agency Staff Budget Manager
Gloucestershire Clinical Commissioning Group’s Constitution - 101 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 10. Expenditure on Charitable and Designated Fund ‐ Sec 20 Endowment Funds Managers in accordance with procedures and limits laid down for charitable funds by the corporate trustee 11. Agreements/Licences/Leases
a) Preparation of all tenancy Director responsible for agreements/licences for all staff Estates subject to CCG Policy on accommodation for staff
b) Initial review of all proposed lease Deputy CFO agreements to assess financial implications of lease agreement
c) Authorisation to sign leases/licences NHS England Signature of all tenancy agreements/licences (as above)
Gloucestershire Clinical Commissioning Group’s Constitution - 102 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner d) extensions to existing licences and Accountable Officer or leases Chief Finance Officer
e) Letting of premises to outside Chief Finance Officer organisations }
f) Approval of rent based on Chief Finance Officer professional assessment
Prime Financial Policies 12. Condemning & Disposal ‐ Sec 18 Maintain losses and special payments Chief Finance Officer register
a) Items obsolete, obsolescent, redundant, irreparable or cannot be required cost effectively
1) with current/estimated purchase Budget Manager price <£499
Gloucestershire Clinical Commissioning Group’s Constitution - 103 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 2) with current purchase new price Chief Finance Officer >£500+
3) Disposal of mechanical and Chief Finance Officer engineering plant (subject to estimated income exceeding £1,000 per sale)
b) Disposal of property or land Governing Body 13. Losses, Write –off & Compensation
a) Losses of cash due to:
1) Theft, Fraud, etc 2) Overpayments of Salaries, wages, fees & allowances 3) Other Causes including un‐vouched or incompletely vouched payments, overpayments other than those included under item 2: physical losses of cash and cash equivalents, e.g. stamps due to fire
Gloucestershire Clinical Commissioning Group’s Constitution - 104 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner (other than arson), accident and similar causes Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) b) Fruitless payments (including abandoned capital Schemes)
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury
Gloucestershire Clinical Commissioning Group’s Constitution - 105 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 11/05) c) Bad debts and claims abandoned:‐
1) Private patients (Sect. 65/ 66 NHS Act 1977) 2) Overseas visitors (Sect. 121 NHS Act 1977) 3) Cases other than 1) – 2)
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) d) Damage to buildings, their fittings, furniture and equipment and loss of equipment and property in stores and in use due to:
Gloucestershire Clinical Commissioning Group’s Constitution - 106 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
1) Culpable causes e.g. theft, Chief Finance Officer fraud, arson or sabotage whether proved or suspected, neglect of duty or gross carelessness
2) Other causes Up to £10,000 Chief Finance Officer Up to 25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) e) Compensation payments made under Governing Body legal obligation
f) Extra contractual payments to contractors
Gloucestershire Clinical Commissioning Group’s Constitution - 107 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05) g) Ex gratia payments to patients & staff for loss of personal effects
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN)
Gloucestershire Clinical Commissioning Group’s Constitution - 108 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 11/05)
h) For clinical negligence (negotiated settlements following legal advice) where the guidance relating to such payments has been applied (including plaintiffs costs) Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05)
For Clinical negligence where the guidance relating to such payments has not been applied
Gloucestershire Clinical Commissioning Group’s Constitution - 109 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Up to £1,000 Chief Finance Officer Up to £5,000 Accountable Officer Over £5,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05)
i) For personal injury claims involving negligence where relevant guidance has been applied (including plaintiffs costs) Up to £1,000 Chief Finance Officer Up to £15,000 Accountable Officer Over £15,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Gloucestershire Clinical Commissioning Group’s Constitution - 110 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05)
For personal injury claims involving negligence where legal advice obtained and relevant guidance has not been applied
Up to £1,000 Chief Finance Officer Up to £5,000 Accountable Officer Over £5,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05)
j) Other clinical negligence cases & personal injury claims
Gloucestershire Clinical Commissioning Group’s Constitution - 111 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
Up to £1,000 Chief Finance Officer Up to £15,000 Accountable Officer Over £15,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05) k) Other, except cases of maladministration where there was no financial loss by claimant
All Governing Body 1) Others 2) Maladministration where there was no financial loss by claimant 3) Patient referrals outside the UK and EEA guidelines 4) Extra statutory and extra
Gloucestershire Clinical Commissioning Group’s Constitution - 112 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner regulationary payments
All Governing Body Prime Financial Policies 14. Reporting of Incidents to the Police ‐ Sec 4 a) Where a criminal offence is suspected Appropriate Manager
criminal offence of a violent nature other
b) Where a fraud is involved Chief Finance Officer or Accountable Officer Prime Financial Policies 15. Petty Cash Disbursements (not ‐ Sec 12 applicable to central Cashiers Office)
General Expenditure up to £25 per As determined by the item Chief Finance Officer
16. Receiving Hospitality
Applies to both individual and Declaration required in CCG Hospitality Register
Gloucestershire Clinical Commissioning Group’s Constitution - 113 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner collective hospitality In excess of £25.00 per item received Prime Financial Policies 17. Implementation of Internal and Budget Manager or ‐ Sec 3 External Audit Recommendations Director Prime Financial Policies 18. Maintenance & Update of CCG Chief Finance Officer ‐ Sec 2 Financial Procedures Prime Financial Policies 19. Personnel & Pay ‐ Sec 16 a) Authority to fill funded post on the Core Team establishment with permanent staff including the ability to alter skill mix within existing budget
b) Authority to appoint staff to post not Accountable Officer on the funded establishment
c) The granting of additional salary HR Lead and Relevant increments to staff within budget Director
d) All requests for upgrading or regrading shall be dealt with in accordance with
Gloucestershire Clinical Commissioning Group’s Constitution - 114 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner CCG Procedure
e) Establishments
1) Additional staff to the agreed Director with the Chief establishment with specifically Finance Officer allocated finance.
2) Additional staff to the agreed Accountable Officer and establishment without specifically Chief Finance Officer allocated finance f) Pay
a) Authority to complete standing HR Lead and Budget data forms effecting pay, new Manager starters, variations and leavers
b) Authority to complete and Budget Manager authorise positive reporting forms
Gloucestershire Clinical Commissioning Group’s Constitution - 115 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
c) Authority to authorise overtime Budget Holder
d) Authority to authorise mileage Line Manager claims, subsistence expenses & exam fees
e) Submission of travel and Employee subsistence claims within 3 months of incurring expenditure
f) Authorisation of travel expenses Chief Finance Officer over 3 months old
g) Authorisation of non travel, Budget Manager Exceptional subsistence or exam fees through circumstances only, expenses claim form supplies procedure should be followed Approval of Performance Related Pay Line/Departmental Assessment Manager
Gloucestershire Clinical Commissioning Group’s Constitution - 116 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner g) Leave } } a) Approval of annual leave } b) Compassionate leave up to 3 days } As per CCG policy c) Compassionate leave up to 6 days } d) Special leave arrangements } Paternity leave } Carers leave 3/5 days } e) Leave without pay } f) Time off in lieu Line manager g) Maternity Leave _ paid and unpaid As per CCG policy h) Sick Leave Extensions of sick leave beyond Director in conjunction CCG terms and Conditions with HR Lead
Return to work part‐time on full Director in conjunction pay day to assist recovery in excess with HR Lead of CCG terms and conditions Extension of sick leave on full pay Accountable Officer or in excess of CCG terms and Chief Finance Officer and conditions HR Lead
Gloucestershire Clinical Commissioning Group’s Constitution - 117 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner i) Study Leave
Study leave outside the UK Accountable Officer All study leave (UK) in excess of CCG Accountable Officer or training procurement Director j) Removal Expenses, Excess Rent and House Purchases
Authorisation of payment of removal expenses in accordance with CCG policy incurred by officers taking up new appointments (providing consideration was promised at interview) Up to £5,000 Director Over £5,000 to £8,000 maximum Accountable Officer or Chief Finance Officer k) Grievance Procedure
All grievances cases must be dealt with HR Lead CCG Grievance strictly in accordance with the Grievance Procedure Procedure and the advice of the Human Resource Manager must be sought when
Gloucestershire Clinical Commissioning Group’s Constitution - 118 - Version: 11. Date: September 2016
Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner the grievance reaches the level of General Manager
l) Authorised Car & Mobile Phone Users
Requests for new posts to be Director and HR Lead authorised as car users Requests for existing post to be Director and HR Lead authorised as car users from the current financial year– standard, regular or lease car users Requests for existing post to be Chief Finance Officer authorised as car users from the prior to current financial year– standard, regular or lease car users Requests for new posts to be Director and HR Lead authorised as mobile telephone users m) Renewal of Fixed Term Contract Director
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner n) Redundancy Accountable Officer / Redeployment and Chief Finance Officer and Redundant policy HR Lead o) Ill Health Retirement
Decision to pursue retirement on the Chief Finance Officer and grounds of ill‐health HR Lead p) Dismissal Director or nominated Disciplinary policy deputy
Prime Financial Policies 20.Insurance Policies and Risk Accountable Officer / ‐ Sec 15 Managment Associate Director Corporate Governance 21. Patients’ & Relatives’ Complaints
a) Overall responsibility for ensuring Accountable Officer and that all complaints are dealt with Associate Director of effectively Patient and Public Involvement b) Responsibilty for ensuring complaints Accountable Officer and
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner relating to directorate are Associate Director of investigated thoroughly Patient and Public Involvement
c) Medico – Legal Complaints ‐ Co Accountable Officer and ordination of their managment Associate Director Corporate Governance 22. Relationships with Press
a) Non‐Emergency General Enquiries
Within Hours Communications Manager
Outside Hours Manager on call or Associate Director of Communications
b) Emergency
Within Hours Communications Manager
Outside Hours Manager on call or
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Associate Director of Communications 23. Infectious Diseases & Notifiable Manager on call or Health Outbreaks Protection Unit Contact or Director of Public Health 24.Facilities for staff not employed by the CCG to gain practical experience Professional Recognition, Honary Contracts, & Insurance of Medical HR Lead Staff Work experience students HR Lead
25. Review of Fire Precautions Director responsible for Health & Safety 26.Review of all statutory compliance Director responsible for legislaton and Health and Safety Health & Safety requirements including control of Substances Hazardous to Health Regulations
27. Review of Medicines Inspectorate Head of Medicines
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Regulations Management
28. Review of compliance with Director responsible for environmental regulations, for Estates example those relating to clean air and waste disposal 29. Review of CCG’s compliance with the Chief Finance Officer Data Protection Act 30. Monitor proposals for contractual Appropriate Director arrangments between the CCG and the outside bodies
31. Review the CCG’s compliance with Chief Finance Officer the Access to Records Act
32. Review of the CCG’s compliance Chief Finance Officer Code of Practice for handling confidential information in the contracting environment and the compliance with “safe Haven” per EL 92/60
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 33. The keeping of a Declaration of Interests Register (a) Board and Executive Committee Associate Director of Members Corporate Governance (b) Staff members Associate Director of Corporate Governance 34. Attestation of sealings in accordance Chair, Accountable Officer with Standing Orders or Chief Finance Officer (a) custody (b) register of sealings 35. The keeping of the register of Accountable Officer Sealings
36. The keeping of the Hospitality Accountable Officer Register
Prime Financial Policies 37. Retention of Records Associate Director of – Sec 19 Corporate Governance
38. Security Management Director responsible for Local Security 39. Contractor’s Responsibilities
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Ensuring contractors and their All employees employees are aware of any requirement to comply with Standing Orders and Prime Financial Policies
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SUMMARY OF KEY RESPONSIBILITIES OF ALL EMPLOYEES UNDER STANDING ORDERS AND PRIME FINANCIAL POLICIES
Responsibility: Of To comply with all procedures implemented by the All employees Governing Body, Accountable Officer or Chief Financial Officer to ensure compliance with Standing Orders and Prime Financial Policies To report instances of non‐compliance with Standing All employees Orders and Prime Financial Policies To act in such a way as to maintain the security of all All employees CCG property To report losses immediately to the Chief Financial All employees Officer following the process laid down To inform the Chief Financial Officer following the All employees process laid down of any income due to the CCG in respect of their area of responsibility To inform the appropriate person, in accordance with All employees the guidance and options laid down, of any suspicion of fraud or corruption To declare in accordance with the procedures laid All employees down, any gifts or hospitality or sponsorship received To declare in accordance with the procedures laid All employees down any interests which may conflict with fulfilment of their role To comply with the Standards of Business Conduct All employees for NHS Staff To set in place arrangements to maintain the security Senior managers of all CCG property within their area of responsibility To comply with the Code of Conduct for NHS Senior Managers Managers To comply with Protocol for Avoidance of Potential All staff as Conflicts of Interest and Potential Unfair Competitive appropriate Advantage.
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APPENDIX F - PRIME FINANCIAL POLICIES
1. INTRODUCTION
1.1. General
1.1.1. These Prime Financial Policies and supporting Detailed Financial Procedures shall have effect as if incorporated into the Group’s Constitution.
1.1.2. The Prime Financial Policies are part of the Group’s control environment for managing the organisation’s financial affairs. They contribute to good corporate governance, internal control and managing risks. They enable sound administration, lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Accountable Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the Scheme of Reservation and Delegation found at Appendix D.
1.1.3. In support of these Prime Financial Policies, the Governing Body has prepared more detailed procedures, approved by the Chief Finance Officer known as detailed financial procedures. The Group refers to these Prime Financial Policies and Detailed Financial Procedures together as the Clinical Commissioning Group’s financial policies.
1.1.4. These Prime Financial Policies identify the financial responsibilities which apply to everyone working for the Group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the Detailed Financial Procedures. The Chief Finance Officer is responsible for approving all Detailed Financial Procedures.
1.1.5. A list of the Clinical Commissioning Group’s Detailed Financial Procedures will be published and maintained on the Group’s website. Documentation will also be available upon request for inspection at:
Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucestershire GL3 4FE
1.1.6. Should any difficulties arise regarding the interpretation or application of any of the Prime Financial Policies then the advice of the Chief Finance Officer must be sought before acting. The user of these Prime Financial Policies should also be familiar with and comply with the provisions of the Group’s Constitution, Standing Orders and Scheme of Reservation and Delegation.
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1.1.7 Failure to comply with Prime Financial Policies and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.
1.2. Overriding Prime Financial Policies
1.2.1. If for any reason these Prime Financial Policies 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’s Audit Committee for referring action or ratification. All of the Group’s members and employees have a duty to disclose any non-compliance with these Prime Financial Policies to the Chief Finance Officer as soon as possible.
1.3. Responsibilities and delegation
1.3.1. The roles and responsibilities of the Group’s members, employees, members of the Governing Body, members of the Governing Body’s committees and sub- committees, members of the Group’s committee and sub-committee (if any) and persons working on behalf of the Group are set out in chapters 6 and 7 of this Constitution.
1.3.2. All Governing Body members and employees who carry out a financial function must keep financial records and discharge their duties in a manner that is satisfactory to the Chief Finance Officer
1.3.3. The financial decisions delegated by members of the Governing Body are set out in the Group’s Scheme of Reservation and Delegation (see Appendix D).
1.4. Contractors and their employees
1.4.1. Any contractor or employee of a contractor who is empowered by the Group to commit the Group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Accountable Officer to ensure that such persons are made aware of this.
1.5. Amendment of Prime Financial Policies
1.5.1. To ensure that these Prime Financial Policies remain up-to-date and relevant, the Chief Finance Officer will review them at least annually. Following consultation with the Accountable Officer and scrutiny by the Governing Body’s Audit Committee, the Chief Finance Officer will recommend amendments, as fitting, to the Governing Body for approval. As these Prime Financial Policies are an integral part of the Group’s Constitution, any amendment will not come into force until the Group applies to NHS England and that application is granted.
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2. INTERNAL CONTROL
POLICY – the Group will put in place a suitable control environment and effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies.
2.1. The Governing Body is required to establish an Audit Committee with terms of reference agreed by the Governing Body (see paragraph 6.6.6 (a) of the Group’s Constitution for further information).
2.2. The Accountable Officer has overall responsibility for the Group’s systems of internal control.
2.3. The Chief Finance Officer will ensure that:
a) financial policies are considered for review and update annually;
b) a system is in place for proper checking and reporting of all breaches of financial policies; and
c) a proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.
3. AUDIT
POLICY – the Group will keep an effective and independent internal audit function and fully comply with the requirements of external audit and other statutory reviews.
3.1. In line with the terms of reference for the Governing Body’s Audit Committee, the person appointed by the Group to be responsible for internal audit and the Audit Commission appointed external auditor will have direct and unrestricted access to Audit Committee members and the Chair of the Governing Body, Accountable Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.
3.2. The person appointed by the Group to be responsible for internal audit and the external auditor will have access to the Audit Committee and the Accountable Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the Governing Body and the Accountable Officer will have direct and unrestricted access to the head of internal audit and external auditors.
3.3. The Chief Finance Officer will ensure that:
a) the Group has a professional and technically competent internal audit function; and
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b) the Governing Body approves any changes to the provision or delivery of assurance services to the Group.
3.4. The Chief Finance Officer or designated internal or external auditor is entitled, without necessarily giving prior notice, to require and receive:
a) Access to all records, documents and correspondence relating to any financial or other relevant transactions including documents of a confidential nature with regards to the business of the Clinical Commissioning Group.
b) Access at all reasonable times to any land, premises or property of the Clinical Commissioning Group.
c) Explanations concerning any matter under investigation.
4. FRAUD AND CORRUPTION
POLICY – the Group requires all staff to always act honestly and with integrity to safeguard the public resources they are responsible for. The group will not tolerate any fraud perpetrated against it and will actively chase any loss suffered.
4.1. The Governing Body’s Audit Committee will satisfy itself that the Group 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.
4.2. The Governing Body’s Audit Committee will ensure that the Group has arrangements in place to work effectively with NHS Protect.
5. EXPENDITURE CONTROL
5.1. The Group is required by statutory provisions63 to ensure that its expenditure does not exceed the aggregate of allotments from NHS England and any other sums it has received and is legally allowed to spend.
5.2. The Accountable Officer has overall executive responsibility for ensuring that the Group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.
5.3. The Chief Finance Officer will:
a) provide reports to NHS England in the form required by NHS England;
b) report the financial position of the Clinical Commissioning Group to the Governing Body.
63 See section 223H of the 2006 Act, inserted by section 27 of the 2012 Act Gloucestershire Clinical Commissioning Group’s Constitution - 130 - Version: 11. Date: September 2016
c) ensure money drawn from NHS England is required for approved expenditure only is drawn down only at the time of need and follows best practice;
d) be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the group to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of NHS England.
6. ALLOTMENTS64
6.1. The Group’s Chief Finance Officer will:
a) periodically review the basis and assumptions used by NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the Group’s entitlement to funds;
b) prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and
c) regularly update the Governing Body on significant changes to the initial allocation and the uses of such funds.
7. COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING
POLICY – the Group will produce and publish an annual operating plan which spans the medium term (i.e. the current and next financial years) and includes reference to the QIPP programme and commissioning intentions, and that explains how the Group proposes to discharge its financial duties. The group will support this with comprehensive medium-term financial plans and annual budgets.
7.1. The Accountable Officer will compile and submit to the Governing Body a commissioning strategy which takes into account financial targets and forecast limits of available resources.
7.2. Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Accountable Officer, prepare and submit budgets for approval by the Governing Body.
7.3. The Chief Financial Officer shall monitor financial performance against budget and plan, periodically review them, and report to the Governing Body. This report should include explanations for variances. These variances must be based on any significant departures from agreed financial plans or budgets.
64 See section 223(G) of the 2006 Act, inserted by section 27 of the 2012 Act. Gloucestershire Clinical Commissioning Group’s Constitution - 131 - Version: 11. Date: September 2016
7.4. Financial monitoring information will also incorporate an assessment of the forecast outturn position based on levels of expenditure being incurred and the risks to non-achievement of the plan.
7.5. The Accountable Officer is responsible for ensuring that information relating to the Group’s accounts or to its income or expenditure, or its use of resources is provided to NHS England as requested.
7.6. The Governing Body will approve consultation arrangements for the Group’s commissioning strategy65.
8. ANNUAL ACCOUNTS AND REPORTS
POLICY – the Group will produce and submit to NHS England accounts and reports in accordance with all statutory obligations66, relevant accounting standards and accounting best practice in the form and content and at the time required by NHS England.
8.1. The Chief Finance Officer will ensure the Group:
a) prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the Governing Body;
b) prepares the accounts according to the timetable approved by the Governing Body;
c) complies with statutory requirements and relevant directions for the publication of annual report;
d) considers the external auditor’s management letter and fully addresses all issues within agreed timescales; and
e) publishes the external auditor’s management letter on the Group’s website.. Documentation will be available upon request for inspection at:
Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucestershire GL3 4FE
65 See section 14Z13 of the 2006 Act, inserted by section 26 of the 2012 Act 66 See paragraph 17 of Schedule 1A of the 2006 Act, as inserted by Schedule 2 of the 2012 Act. Gloucestershire Clinical Commissioning Group’s Constitution - 132 - Version: 11. Date: September 2016
9. INFORMATION TECHNOLOGY
POLICY – the group will ensure the accuracy and security of the group’s computerised financial data.
9.1. The Chief Finance Officer is responsible for the accuracy and security of the Group’s computerised financial data and shall:
a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Group's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;
b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;
c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;
d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Chief Finance Officer may consider necessary are being carried out.
9.2. In addition the Chief Finance Officer shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.
10. ACCOUNTING SYSTEMS
POLICY – the Group will run an accounting system that creates management and financial accounts.
10.1. The Chief Finance Officer will ensure:
a) the Group has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of NHS England;
b) that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
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10.2. Where another health organisation or any other agency provides a computer service for financial applications, the Chief Finance Officer shall periodically seek assurances that adequate controls are in operation.
11. BANK ACCOUNTS
POLICY – the Group will keep enough liquidity to meet its current commitments.
11.1. The Chief Finance Officer will:
a) review the banking arrangements of the Group at regular intervals to ensure they are in accordance with Secretary of State directions67, best practice and represent best value for money;
b) manage the Group's banking arrangements and advise the Group on the provision of banking services and operation of accounts;
c) prepare detailed instructions on the operation of bank accounts.
11.2. The Accountable Officer shall approve the banking arrangements.
12. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS.
POLICY – the Group will: . operate a sound system for prompt recording, invoicing and collection of all monies due; . seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the group or its functions;68 . ensure its power to make grants and loans is used to discharge its functions effectively.69
12.1. The Chief Financial Officer is responsible for:
a) designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due;
b) establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;
c) approving and regularly reviewing the level of all fees and charges other than those determined by NHS England or by statute. Independent professional advice on matters of valuation shall be taken as necessary;
67 See section 223H(3) of the NHS Act 2006, inserted by section 27 of the 2012 Act 68 See section 14Z5 of the 2006 Act, inserted by section 26 of the 2012 Act. 69 See section 14Z6 of the 2006 Act, inserted by section 26 of the 2012 Act. Gloucestershire Clinical Commissioning Group’s Constitution - 134 - Version: 11. Date: September 2016
d) developing effective arrangements for making grants or loans.
13. TENDERING AND CONTRACTING PROCEDURE
POLICY – the Group: . will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending; . will seek value for money for all goods and services; . shall ensure that competitive tenders are invited for . the supply of goods, materials and manufactured articles; . the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health); and . for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals.
13.1. The Group shall ensure that the firms / individuals invited to tender (and where appropriate, quote) are among those on approved lists or where necessary a framework agreement. Where in the opinion of the Chief Finance Officer it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Accountable Officer or the Group’s Governing Body.
13.2. The Governing Body may only negotiate contracts on behalf of the Group, and the Group may only enter into contracts, within the statutory framework set up by the 2006 Act, as amended by the 2012 Act. Such contracts shall comply with:
a) the Group’s Standing Orders;
b) the Public Contracts Regulation 2006, any successor legislation and any other applicable law; and
c) take into account as appropriate any applicable NHS England or the Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (b) above.
13.3. In all contracts entered into, the Group shall endeavour to obtain best value for money. The Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group.
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14. COMMISSIONING
POLICY – working in partnership with relevant national and local stakeholders, the Group will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility.
14.1. The Group will coordinate its work with NHS England, other clinical commissioning groups, local providers of services, local authority(ies), including through Health & Wellbeing Boards, patients and their carers and the voluntary sector and others as appropriate to develop robust commissioning plans.
14.2. The Accountable Officer will establish arrangements to ensure that regular reports are provided to the Governing Body detailing actual and forecast expenditure and activity for each contract.
14.3. The Chief Finance Officer will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.
15. RISK MANAGEMENT AND INSURANCE
POLICY – the Group will put arrangements in place for evaluation and management of its risks.
15.1. The CCG will adopt a Risk Management Strategy that will outline the organisation’s approach to managing risk. A key feature of the strategy will be the maintenance of a Risk Register that will be used to record and monitor risks. It is intended that the Risk Register will be presented to each meeting of the Integrated Governance and Quality Committee to provide on-going oversight and review.
15.2. An Assurance Framework will also be maintained to provide details of the assurances that will be provided to the Governing Body regarding the achievement of the organisation’s Annual Objectives. The Assurance Framework will identify gaps in assurances and controls regarding the objectives, along with details of the major risks that have been identified. The Assurance Framework will also be presented to each meeting of the Integrated Governance and Quality Committee as part of the oversight and review activity.
16. PAYROLL
POLICY – the Group will put arrangements in place for an effective payroll service.
16.1. The Chief Finance Officer will ensure that the payroll service selected: Gloucestershire Clinical Commissioning Group’s Constitution - 136 - Version: 11. Date: September 2016
a) is supported by appropriate (i.e. contracted) terms and conditions;
b) has adequate internal controls and audit review processes;
c) has suitable arrangements for the collection of payroll deductions and payment of these to appropriate bodies.
16.2. In addition the Chief Finance Officer shall set out comprehensive procedures for the effective processing of payroll.
17. NON-PAY EXPENDITURE
POLICY – the Group will seek to obtain the best value for money goods and services received.
17.1. The Governing Body will approve the level of non-pay expenditure on an annual basis and the Accountable Officer will determine the level of delegation to budget managers.
17.2. The Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services.
17.3. The Chief Finance Officer will:
a) advise the Accountable Officer on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the scheme of reservation and delegation;
b) be responsible for the prompt payment of all properly authorised accounts and claims;
c) be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable.
18. CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS
POLICY – the Group will put arrangements in place to manage capital investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the Group’s fixed assets.
18.1. The Accountable Officer will:
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a) ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;
b) be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;
c) shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges;
d) be responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.
18.2. The Chief Finance Officer will prepare detailed procedures for the disposals of assets.
19. RETENTION OF RECORDS
POLICY – the Group will put arrangements in place to retain all records in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance.
19.1. The Accountable Officer shall:
a) be responsible for maintaining all records required to be retained in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance;
b) ensure that arrangements are in place for effective responses to Freedom of Information requests;
c) publish and maintain a Freedom of Information Publication Scheme.
20. TRUST FUNDS AND TRUSTEES
POLICY – the Group will put arrangements in place to provide for the appointment of trustees if the group holds property on trust.
20.1. The Chief Finance Officer shall ensure that each trust fund which the Group is responsible for managing is managed appropriately with regard to its purpose and to its requirements.
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APPENDIX G E - NOLAN PRINCIPLES
The ‘Nolan Principles’ set out the ways in which holders of public office should behave in discharging their duties. The seven principles are: a) Selflessness – Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. b) Integrity – Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. c) Objectivity – In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards d) and benefits, holders of public office should make choices on merit. e) Accountability – Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. f) Openness – Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. g) Honesty – Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. h) Leadership – Holders of public office should promote and support these principles by leadership and example.
Source: The First Report of the Committee on Standards in Public Life (1995)70
70 Available at http://www.public-standards.gov.uk/ Gloucestershire Clinical Commissioning Group’s Constitution - 139 - Version: 11. Date: September 2016
APPENDIX H F – SEVEN KEY PRINCIPLES OF THE NHS CONSTITUTION
The NHS Constitution sets out seven key principles that guide the NHS in all it does:
1. the NHS provides a comprehensive service, available to all - irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population
2. access to NHS services is based on clinical need, not an individual’s ability to pay - NHS services are free of charge, except in limited circumstances sanctioned by Parliament.
3. the NHS aspires to the highest standards of excellence and professionalism - in the provision of high-quality care that is safe, effective and focused on patient experience; in the planning and delivery of the clinical and other services it provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population.
4. NHS services must reflect the needs and preferences of patients, their families and their carers - patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.
5. the NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population - the NHS is an integrated system of organisations and services bound together by the principles and values now reflected in the Constitution. The NHS is committed to working jointly with local authorities and a wide range of other private, public and third sector organisations at national and local level to provide and deliver improvements in health and well-being
6. the NHS is committed to providing best value for taxpayers’ money and the most cost-effective, fair and sustainable use of finite resources - public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves
7. the NHS is accountable to the public, communities and patients that it serves - the NHS is a national service funded through national taxation, and it is the Government which sets the framework for the NHS and which is accountable to Parliament for its operation. However, most decisions in the NHS, especially those about the treatment of individuals and the detailed organisation of services, are rightly taken by the local NHS and by patients with their clinicians. The system of responsibility and accountability for taking decisions in the NHS Gloucestershire Clinical Commissioning Group’s Constitution - 140 - Version: 11. Date: September 2016
should be transparent and clear to the public, patients and staff. The Government will ensure that there is always a clear and up-to-date statement of NHS accountability for this purpose
Source: The NHS Constitution: The NHS belongs to us all (March 2012)71
71 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132961 Gloucestershire Clinical Commissioning Group’s Constitution - 141 - Version: 11. Date: September 2016
APPENDIX I – CHECKLIST FOR A Formatted: Centered CLINICAL COMMISSIONING GROUP’S CONSTITUTION Formatted: Adjust space between Latin and Asian text, Adjust space between Asian text and numbers Essential/ Included Formatted: Centered, Adjust space Content Optional between Latin and Asian text, Adjust space between Asian text and numbers Essential The constitution must specify: Formatted: Adjust space between the name of the clinical commissioning group; Latin and Asian text, Adjust space the members of the group; and between Asian text and numbers the area of the group Formatted: Centered, No bullets or numbering, Adjust space between Latin and Asian text, Adjust space between The name of the group must comply with such requirements as may Asian text and numbers be prescribed Formatted: Centered, Adjust space between Latin and Asian text, Adjust Essential The constitution must specify the arrangements made by the space between Asian text and numbers clinical commissioning group for the discharge of its functions Formatted: Centered, Adjust space (including its functions in determining the terms and conditions of its between Latin and Asian text, Adjust employees) space between Asian text and numbers Optional The arrangements may include provision: Formatted: Adjust space between Latin and Asian text, Adjust space for the appointment of committees or sub-committees of the between Asian text and numbers clinical commissioning group; and Formatted: Centered, Adjust space for any such committees to consist of or include persons between Latin and Asian text, Adjust other than members or employees of the clinical commissioning space between Asian text and numbers group Formatted: Adjust space between Latin and Asian text, Adjust space Optional The arrangements may include provision for any functions of the between Asian text and numbers clinical commissioning group to be exercised on its behalf by: Formatted: Centered, No bullets or any of its members or employees; numbering, Adjust space between Latin its governing body; or and Asian text, Adjust space between Asian text and numbers a committee or sub-committee of the group Formatted: Centered, Adjust space Essential The constitution must specify the procedure to be followed by the between Latin and Asian text, Adjust clinical commissioning group in making decisions space between Asian text and numbers Formatted: Adjust space between Essential The constitution must specify the arrangements made by the Latin and Asian text, Adjust space clinical commissioning group for discharging its duties in between Asian text and numbers respect of registers of interest and management of conflicts of Formatted: Centered, No bullets or interest as specified under section 14O(1) to (4) of the 2006 Act, as numbering, Adjust space between Latin inserted by section 25 of the 2012 Act and Asian text, Adjust space between Asian text and numbers Essential The constitution must also specify the arrangements made by the Formatted: Centered, Adjust space clinical commissioning group for securing that there is between Latin and Asian text, Adjust transparency about the decisions of the group and the manner space between Asian text and numbers in which they are made Formatted: Adjust space between Latin and Asian text, Adjust space between Asian text and numbers The provisions made above must secure that there is effective participation by each member of the clinical commissioning group in Formatted ... [1] the exercise of the group’s functions Formatted ... [2] Essential The constitution must specify the arrangements made by the Formatted ... [3] clinical commissioning group for the discharge of the functions Formatted ... [4] of its governing body Formatted ... [5] Essential The arrangements must include: Formatted ... [6]
provision for the appointment of the audit committee and Formatted ... [7] remuneration committee of the governing body Formatted ... [9] Formatted ... [8] Gloucestershire Clinical Commissioning Group’s Constitution - 142 - Version: 11. Date: September 2016
Essential/ Included Formatted: Adjust space between Content Optional Latin and Asian text, Adjust space between Asian text and numbers Optional The arrangements may include: Formatted: Centered, Adjust space provision for the audit committee (but not the remuneration between Latin and Asian text, Adjust committee) to include individuals who are not members of the space between Asian text and numbers governing body Formatted: Adjust space between provision for the appointment of other committees or sub- Latin and Asian text, Adjust space between Asian text and numbers committees of the governing body. These may include provision for Formatted: Centered, No bullets or a committee or sub-committee to include individuals who are not numbering, Adjust space between Latin members of the governing body but are: and Asian text, Adjust space between o members of the clinical commissioning group, or Asian text and numbers o individuals of a description specified in the constitution
Optional The arrangements may include provision for any functions of the Formatted: Centered, Adjust space governing body to be exercised on its behalf by: between Latin and Asian text, Adjust space between Asian text and numbers any committee or sub-committee of the governing body, a member of the governing body; Formatted: Adjust space between Latin and Asian text, Adjust space a member of the clinical commissioning group who is an between Asian text and numbers individual (but is not a member of the governing body); or Formatted: Centered, No bullets or an individual of a description specified in the constitution numbering, Adjust space between Latin and Asian text, Adjust space between Essential The constitution must specify the procedure to be followed by the Asian text and numbers governing body in making decisions Formatted: Centered, Adjust space between Latin and Asian text, Adjust Essential The constitution must also specify the arrangements made by the space between Asian text and numbers clinical commissioning group for securing that there is Formatted: Adjust space between transparency about the decisions of the governing body and Latin and Asian text, Adjust space the manner in which they are made between Asian text and numbers Formatted: Centered, Adjust space This provision must include provision for meetings of governing between Latin and Asian text, Adjust bodies to be open to the public, except where the clinical space between Asian text and numbers commissioning group considers that it would not be in the public Formatted: Adjust space between interest to permit members of the public to attend a meeting or part Latin and Asian text, Adjust space between Asian text and numbers of a meeting
Essential In its constitution, the clinical commissioning group must describe Formatted: Centered, Adjust space the arrangements which it has made and include a statement of the between Latin and Asian text, Adjust principles which it will follow in implementing those arrangements, to space between Asian text and numbers secure that individuals to whom health services are being or Formatted: Adjust space between Latin and Asian text, Adjust space may be provided pursuant to its commissioning arrangements between Asian text and numbers are involved (whether by being consulted or provided with information or in other ways): in the planning of the commissioning arrangements by the Formatted: Centered, No bullets or group; numbering, Adjust space between Latin and Asian text, Adjust space between in the development and consideration of proposals by the Asian text and numbers group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them; and in decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact
Gloucestershire Clinical Commissioning Group’s Constitution - 143 - Version: 11. Date: September 2016
Appendix JG Gloucestershire Clinical Commissioning Group Governance Structure
Gloucestershire Clinical Commissioning Group
Audit Integrated Remuneration Priorities Primary Care Committee Governance and Committee Committee Commissioning Chief Finance Quality Committee Accountable Committee Officer Executive Nurse & Officer Quality Lead
Commissioning for Quality GroupClinical Quality Review Groups
Gloucestershire Safeguarding Children’s Board Joint Commissioning Boards Gloucestershire Safeguarding Adults Board
Clinical Effectiveness Sub‐ Committee
Information Governance Working Group
Individual Funding Request Panel
Equality and Health Inequalities Working Group
Gloucestershire Clinical Commissioning Group’s Constitution - 144 - Version: 11. Date: September 2016
Appendix K
NHS Gloucestershire Clinical Commissioning Group
Governing Body Audit Committee
Terms of Reference
Gloucestershire Clinical Commissioning Group’s Constitution - 145 - Version: 11. Date: September 2016
1. Introduction
1.1. The Audit Committee (the Committee) is established in accordance with Gloucestershire Clinical Commissioning Group’s Constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the Constitution.
2. Membership
2.1. The Committee shall be appointed by the Clinical Commissioning Group as set out in the Clinical Commissioning Group’s Constitution and may include individuals who are not on the Governing Body.
2.2. The membership of the Audit Committee shall include:-
. the lay member of the Governing Body with a lead role in overseeing key elements of governance . two other lay members . two GP Governing Body members
2.3. The lay member on the Governing Body, with a lead role in overseeing key elements of governance, will chair the audit committee.
2.4. In the event of the Chair of the Committee being unable to attend all or part of the meeting, he or she will nominate a replacement from within the membership to deputise for that meeting.
2.5. The Chair of the Governing Body shall not be a member of the Audit Committee.
2.6. Members of the Committee shall cease to be members of the Committee if they are no longer members of the Governing Body.
2.7. The members from the GP member practices of the Governing Body shall not be in the majority.
3. Attendance
3.1. The Committee shall invite the Chief Finance Officer, the respective internal and external auditors and a representative of NHS Protect/Counter Fraud to attend meetings of the Committee.
3.2. Additionally the Committee may invite any individual to attend any or part of its meetings.
3.3. The Committee may invite any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the Committee and shall withdraw upon request.
3.4. Any individual invited to attend the Committee may contribute to the proceedings and provide advice and/or guidance to the Committee as requested.
3.5. Notwithstanding the above provisions, external audit, internal audit and local counter fraud and security management providers will have full and unrestricted rights of access to the committee in respect of their audit functions.
Gloucestershire Clinical Commissioning Group’s Constitution - 146 - Version: 11. Date: September 2016
4. Secretary
4.1. The Committee Secretary shall be the Associate Director Corporate Services.
5. Quorum
5.1. The quorum of the Committee shall be three members, two of whom must be lay members.
6. Frequency and notice of meetings
6.1. The Committee shall meet not less than four times each financial year.
6.2. The Chair of the Committee may convene additional meetings as required.
6.3. The external auditor or internal auditor may requisition a meeting of the Committee if it is deemed necessary.
6.4. Written notice of meetings and the agenda shall be provided to Committee members not less than 5 working days before the meeting.
6.5. Notice of Committee meetings and the agenda shall also be provided to the Accountable Officer, Chief Finance Officer and the Clinical Commissioning Group employee responsible for internal audit.
6.6. The Committee shall meet in private with the internal and external auditors not less than annually.
6.7. The Committee shall meet with the Accountable Officer not less than annually to discuss and consider the process for assurance that supports the Governance Statement.
7. Remit and responsibilities of the Committee
7.1. The Committee shall critically review the Clinical Commissioning Group’s financial reporting and internal control principles and ensure an appropriate relationship with both internal and external auditors is maintained.
7.2. The key duties of the Committee are:-
Integrated governance, risk management and internal control
7.3. The Committee shall review the establishment of an effective system of integrated governance, risk management and internal control, across the whole of the Clinical Commissioning Group’s activities that support the achievement of the Clinical Commissioning Group’s objectives.
7.4. 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 Clinical Commissioning Group. . the underlying assurance processes that indicate the degree of achievement of the Clinical Commissioning Group’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. Gloucestershire Clinical Commissioning Group’s Constitution - 147 - Version: 11. Date: September 2016
. 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.
7.5. In carrying out this work the Committee will 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 governance, risk management and internal control, together with indicators of their effectiveness.
7.6. This will be evidenced through the Committee’s use of an effective assurance structure to guide its work and that of the audit and assurance functions that report to it.
Internal Audit
7.7. 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 audit committee, Accountable Officer and the Clinical Commissioning Group. This will be achieved by:
. Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal. . Review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the assurance framework. . Considering the major findings of internal audit work (and management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources. . Ensuring that the internal audit function is adequately resourced and has appropriate standing within the clinical commissioning group. . An annual review of the effectiveness of internal audit.
External audit
7.8. The Committee shall review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:
. Consideration of the performance of the external auditors, as far as the rules governing the appointment permit. . Discussion and agreement with the external auditors, before the audit commences, on the nature and scope of the audit as set out in the annual plan, and ensuring co- ordination, as appropriate, with other external auditors in the local health economy. . Discussion with the external auditors of their local evaluation of audit risks and assessment of the Clinical Commissioning Group and associated impact on the audit fee. . Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Clinical Commissioning Group and any work undertaken outside the annual audit plan, together with the appropriateness of management responses. . To review advice received from the external auditors regarding regulatory issues.
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Other assurance functions
7.9. The Audit Committee shall review the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the Clinical Commissioning Group.
7.10. These will include, but will not be limited to, any reviews by Department of Health arms- length bodies or regulators/inspectors (for example, the Care Quality Commission and NHS Litigation Authority) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).
Counter fraud
7.11. The Committee shall satisfy itself that the Clinical Commissioning Group 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.
Management
7.12. The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
7.13. The Committee may also request specific reports from individual functions within the Clinical Commissioning Group as they may be appropriate to the overall arrangements.
Financial reporting
7.14. The Audit Committee shall monitor the integrity of the financial statements of the Clinical Commissioning Group and any formal announcements relating to the Clinical Commissioning Group’s financial performance.
7.15. The Committee shall ensure that the systems for financial reporting to the Clinical Commissioning Group, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Clinical Commissioning Group.
7.16. The Audit Committee shall review the annual report and financial statements before submission to the Clinical Commissioning Group, 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.
8. Relationship with the Governing Body
Authority Gloucestershire Clinical Commissioning Group’s Constitution - 149 - Version: 11. Date: September 2016
8.1. The Committee is authorised by the Governing Body to obtain professional advice, including the appointment of external advisor and/or consultants, related to its functions as it deems fit at the expense of the Clinical Commissioning Group.
8.2. The Committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the Committee to fulfil its terms of reference.
Monitoring and Reporting
8.3. The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body.
8.4. The Chair of the Committee shall report the outcome and any recommendations of the committee to the Governing Body.
8.5. The Committee shall report to the Governing Body annually on its work in support of the Statement of Internal Control, specifically commenting on the fitness for purpose of the Assurance Framework process. The Assurance Framework is presented regularly to the Governing Body.
9. Policy and best practice
9.1. The Committee shall have regard to current good practice, policies and guidance issued by the NHS England, the Clinical Commissioning Group and other relevant bodies.
10. Conduct of the Committee
10.1. The Committee shall conduct its business in accordance with these terms of reference and the Clinical Commissioning Group’s governance arrangements.
Gloucestershire Clinical Commissioning Group’s Constitution - 150 - Version: 11. Date: September 2016
Appendix L
NHS Gloucestershire Clinical Commissioning Group
Governing Body Remuneration Committee
Terms of Reference
Gloucestershire Clinical Commissioning Group’s Constitution - 151 - Version: 11. Date: September 2016
1. Introduction
1.1 The remuneration committee (the committee) is established in accordance with NHS Gloucestershire Clinical Commissioning Group’s constitution, standing orders and scheme of delegation. 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 clinical commissioning group’s constitution and standing orders.
2. Membership
2.1 The committee shall be appointed by the clinical commissioning group from amongst its governing body members. The members shall include:-
. All Lay members of the Governing Body . CCG Chair . 2 GP members of the Governing Body
2.2 The non-clinical Vice Chair shall be the Chair of the committee.
2.3 No one other than the members of the committee is entitled to be present at committee meetings. The Accountable Officer will only attend when the remuneration and terms of service of other Directors is being discussed
2.4 The committee may invite any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the committee and shall withdraw upon request.
3. Secretary
3.1 The committee secretary shall be the Associate Director Corporate Governance
4. Quorum
4.1 The quorum of the committee shall be three members.
5. Frequency and notice of meetings
5.1 The committee shall meet not less than twice a year.
5.2 Written notice of the date, venue and agenda shall be circulated to all committee members not less than 5 working days before the proposed date.
5.3 The Chair of the committee may convene additional meetings as required.
5.4 The minutes of committee meetings shall be circulated as soon as is practicable after the meeting to which they relate to members of the committee and the Accountable Officer.
6. Remit and responsibilities of the committee
6.1 The committee shall make recommendations to the governing body on determinations about pay and remuneration for employees of the clinical commissioning group and people who provide services to the clinical commissioning group and allowances under any pension scheme it might establish as an alternative to the NHS pension scheme. Gloucestershire Clinical Commissioning Group’s Constitution - 152 - Version: 11. Date: September 2016
6.2 Specifically the committee shall undertake the following:-
6.2.1 determine the policy regarding terms of service and remuneration of the members of the Governing Body having regard to the provisions of national arrangements where appropriate;
6.2.2 have delegated authority to review the performance and determine the individual remuneration arrangements including any performance related pay for members of the Governing Body;
6.2.3 consult with the Accountable Officer and Chair of the Governing Body in relation to their proposals relating to the remuneration of members of the Senior Management Team;
6.2.4 approve any changes to the standard contract of employment for members of the Governing Body, where applicable, including termination arrangements taking into account relevant guidance and current good practice;
6.2.5 agree terms for the termination of a contract having regard to HM Treasury guidance and current good practice;
7. Relationship with the governing body
Authority
7.1 The committee is authorised by the Governing Body to obtain legal advice, remuneration or other professional advice, including the appointment of external advisor and/or consultants, related to its functions as it deems fit at the expense of the clinical commissioning group.
7.2 The committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the committee to fulfill its terms of reference.
Monitoring and Reporting
7.3 The minutes of each meeting of the committee shall be formally recorded and retained by the clinical commissioning group. The minutes shall be submitted to the Governing Body.
7.4 The Chair of the committee shall report the outcome and any recommendations of the committee to the Governing Body.
8. Policy and best practice
8.1 The committee shall have regard to current good practice; policies; and guidance issued by the National Commissioning Board, the clinical commissioning group and other relevant bodies.
9. Conduct of the committee
9.1 The committee shall conduct its business in accordance with these terms of reference and the clinical commissioning group’s governance arrangements.
Gloucestershire Clinical Commissioning Group’s Constitution - 153 - Version: 11. Date: September 2016
Appendix M
NHS Gloucestershire Clinical Commissioning Group
Integrated Governance & Quality Committee
Terms of Reference
Gloucestershire Clinical Commissioning Group’s Constitution - 154 - Version: 11. Date: September 2016
1. Aims
1.1 The aim of the Integrated Governance and Quality Committee is to continuously improve the delivery of healthcare services to the people of Gloucestershire, so ensuring that the services are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements. We will do this by ensuring that controls are in place and are operating efficiently and effectively to deliver the principal objectives of the Governing Body and to set in place processes to manage identified risks, minimising the Clinical Commissioning Group’s exposure to corporate, financial and clinical risks. The Committee will have a pro-active approach to the management of risk and quality, ensuring the organisation learns and takes appropriate corrective action.
2. Core Membership
2.1 The Committee shall be appointed by the Clinical Commissioning Group from amongst its Governing Body members. The members shall include:-
. 3 Lay Members . Clinical Chair of the CCG
. Accountable Officer
. Chief Financial Officer
. Director of Public Health
. Registered Nurse
. Executive Nurse & Quality Lead
. Director of Commissioning Implementation
. 4 GP Governing Body Members
2.2 The Registered Nurse shall be the Chair and one of the GP Members the Vice-Chair of the Committee.
2.3 The Committee may require any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the Committee and shall withdraw upon request.
3. Secretary
3.1 The Committee secretary shall be the Associate Director of Corporate Governance.
4. Quorum
4.1 Four members of the Committee must be present including at least one clinician member, two lay members and an executive member for the quorum to be established.
5. Frequency and notice of meetings
5.1 The Committee shall meet bi-monthly.
5.2 Written notice of the date, venue and agenda shall be circulated to all Committee Gloucestershire Clinical Commissioning Group’s Constitution - 155 - Version: 11. Date: September 2016
members not less than 5 working days before the proposed date.
5.3 The Chair of the Committee may convene additional meetings as required.
5.4 The minutes of Committee meetings shall be circulated by the Chair as soon as is practicable after the meeting to which they relate to all members of the committee.
6. Remit and responsibilities of the Committee
6.1 The Committee is responsible for the overall development of the Integrated Governance Strategy and to ensure that the appropriate governance plans and mechanisms are in place and being monitored across the following areas:-
. Corporate Governance
. Clinical Effectiveness
. Patient Experience
. Clinical Audit
. Risk Management
. Serious Incident reporting
. Infection Control
. Equality & Diversity
. Service Planning
. Performance in respect of commissioned services
. Information Governance
. Child and Adult Safeguarding
. Health and Safety
. Human Resources
. Research Governance
. Information Governance
7. Governance
Through the delegated authority from the Governing Body the Committee will:
7.1 Monitor and facilitate Clinical Commissioning Gloucestershire compliance against external standards, good practice guidance and legislation;
7.2 Receive assurances that the CCG responds appropriately to reports from external agencies relevant to integrated governance, e.g. Care Quality Commission, Audit Commission, NICE, Monitor, Health and Safety Executive, NHS Litigation Authority, NHS England Area Team;
7.3 Monitor the Risk Register and Board Assurance Framework ensuring that risks are appropriately prioritised and adequately controlled and that all high and extreme risks
Gloucestershire Clinical Commissioning Group’s Constitution - 156 - Version: 11. Date: September 2016
are communicated to the Governing Body;
7.4 Review the Committee arrangements to ensure that they remain structurally fit for purpose and to make recommendations for amendments to the Governing Body as appropriate;
7.5 Receive reports from the Local Children and Adult Safeguarding Boards including serious case review reports; and
7.6 Review and approve polices on behalf of the Governing Body. This excludes those policies which the Committee considers to be central to the function of the CCG which the Committee will recommend to the Governing Body for approval anf financial policies which will be considered by the Audit Committee
8. Quality Governance
The assurance of quality services commissioned by the CCG will be underpinned by the six dimensions of healthcare quality. We will therefore work to ensure services to the people of Gloucestershire are:
Person-centred; Safe; Effective; Efficient; Equitable and Timely.
We will do this by:
8.1 Ensuring appropriate mechanisms are in place to monitor and drive-forward the quality and safety of services commissioned by the CCG, recommending courses of action where concerns have been identified. Using measures for improvement to assure the Committee of progress in developing services to meet the patient / client’s needs.
8.2 Receiving and mandating action on reports on quality in respect of the CCG’s commissioned services (acute, mental health, community, independent and any willing/qualified provider); the reports will cover provider performance against CQUINs; patient experience (including complaints and compliments we receive as commissioners), patient safety and clinical performance indicators.
8.3 As part of the annual planning cycle, agree the CQUIN schedule and review implementation by providers.
8.4 Ensuring the patient voice is listened to in order to understand the diversity of the patient experience. This will include consideration of complaints and compliments received by the CCG. The Committee with also receive patient stories at their meetings and consider service delivery from a patient’s perspective in undertaking their governance role.
8.5 Receiving, reviewing and scrutinising reports on serious incidents (SIs) occurring in commissioned services and monitor associated action plans. Requesting additional action / information as necessary, gaining assurance that provider organisations have learnt lessons and taken appropriate action.
8.6 Considering national quality reports and results from relevant national audits and ensuring actions are taken where necessary.
8.7 Reviewing performance against quality indicators in the NHS Outcomes Framework and receiving assurances that concerns are appropriately addressed.
8.8 Receiving assurances that appropriate systems are in place for the development and review of care pathways, clinical policies and the implementation of NICE guidance and quality standards.
8.9 Reviewing non-financial performance indicators; identifying key areas of focus e.g. infection control. Gloucestershire Clinical Commissioning Group’s Constitution - 157 - Version: 11. Date: September 2016
8.10 Receiving internal and external audits reports relating to quality and follow up action plans
8.11 Ensuring adequate systems are in place for the governance of research in line with the Department of Health’s requirements.
8.12 Monitoring that arrangements are in place within the CCG relating to equality and diversity issues, ensuring compliance with statutory obligations and implementation of equality plans.
8.13 Annually review and critique the provider quality accounts.
9. Relationship with the governing body
Authority
9.1 The Committee is authorised to conduct its activities that provide assurance to the Governing Body in relation to the following:-
There is an appropriate and fit for purpose range of systems, policies and procedures in place to manage all risks; It has fulfilled its responsibility to manage risk by providing evidence of compliance with all risk management processes The Assurance Framework accurately reflects the organisations objectives and that the associated risks are identified together with the measures and controls to manage these principal risks;
9.2 The Committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the Committee to fulfil its terms of reference.
Monitoring and Reporting
9.3 The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body.
9.4 The Chair of the Committee shall report the outcome and any recommendations of the committee to the next available Governing Body.
10. Policy and best practice
10.1 The Committee shall have regard to current good practice; policies; and guidance issued by the National Commissioning Board, the Clinical Commissioning Group and other relevant bodies.
11. Conduct of the Committee
11.1 The Committee shall conduct its business in an open and responsive manner and in accordance with these terms of reference and the Clinical Commissioning Group’s governance arrangements.
12. Sub-Committees
12.1 The following sub-committees will report to the Integrated Governance & Quality committee and will submit the minutes of their meetings to the Committee for review:
Policy Working Group Clinical Effectiveness sub-committee Information Governance working group Gloucestershire Clinical Commissioning Group’s Constitution - 158 - Version: 11. Date: September 2016
Individual Funding Request (IFR) panel Equality and Health Inequalities Working Group
Gloucestershire Clinical Commissioning Group’s Constitution - 159 - Version: 11. Date: September 2016
Appendix N
NHS Gloucestershire Clinical Commissioning Group
Priorities Committee Terms of Reference
Strategic purpose The CCG has established a prioritisation process comprising a Prioritisation Framework, a Priorities Committee and individual Funding Request panel. The purpose of the Priorities Committee is to advise the local NHS health economy as to the health care interventions and policies that should be given high or low priority. The priorities committee helps the CCG and its Localities choose how to allocate its resources to promote the health of the local community, based on the local health needs assessment.
Purpose The purpose of the Priorities Committee is to guide and underpin the decision making processes of the CCG and it further supports a consistent approach to commissioning by: • Providing a coherent structure for discussion, ensuring all important aspects of each issue are considered. • Promoting fairness and consistency in decision making from meeting to meeting and with regard to different clinical topics, reducing the potential for inequity. • Providing a means of expressing the reasons behind the decisions made. • Reducing risk of judicial review by implementation of robust decision making processes that are based on evidence of clinical and cost effectiveness within an Ethical Framework. • Supporting and integrating with the development of CCG Commissioning Plans.
Key responsibilities as delegated by the Governing Body:
To set the organisational priorities within which commissioning plans are developed. To provide guidance to the clinical programme groups on the priority areas for their work. To agree programme scope and outcomes to deliver organisational priorities and deliver transformational change. To use a transparent prioritisation framework to agree commissioning priorities, plans and projects; this includes decisions regarding investment, service redesign and disinvestment.
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To review the robustness of the prioritisation framework annually or more frequently if necessary. To agree indicative resources to programmes using a programme budgeting approach. To supervise the development of an annual programme plan for each clinical programme group, that outlines the key priorities and makes explicit the links to the CCG overall strategic objectives, using the programme budget to understand the overall cost of the programme and support decision-making. To receive recommendations (programme business case) for investment, disinvestment and service redesign at least annually. To monitor and resolve impacts between programmes and barriers to progress that require strategic input. To understand the aggregate impact of all clinical programmes on key providers and ensure alignment with overall strategic objectives recommending adjustments to individual programme business cases as required. To ensure that localities and locality plans are sufficiently represented within the programme plans both as generators of evidence/ideas but also as stakeholders with whom the programme consults and as implementation leads. To seek assurance from programme leads that they have consulted with other key stakeholders including partner organisations and communities of interest for that programme and to carry out more strategic consultations through CCG representation at key events and meetings. To sign off the programme business cases ensuring they are resourced and deliverable within the overall organisational financial plans. To agree specific outputs from clinical programme groups as required e.g. new care pathways. To receive and review a programme plan to deliver the business case and receive reports that monitor progress against programme outcomes with quarterly programme updates that demonstrate that the programme plan is delivering.
Membership:
Chair – Clinical Commissioning Group - Chair Vice Chair – Deputy Clinical Chair
Members (or their delegated representatives) CCG GP Governing Body Members CCG Lay Governing Body Members CCG Executive Governing Body Members CCG Healthcare Professional Governing Body Members Director of Public Health (GCC) Director of Adult Services (GCC)
Other CCG staff or representative from other organisations will be invited to attend for specific items on the agenda.
Accountability and reporting:
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The CCG Priorities Committee will be accountable to Gloucestershire Clinical Commissioning Group Governing Body. The Committee will have delegated powers to make decisions on behalf of the governing body as described in the CCG Governing Body constitution.
The CCG Priorities Committee will be responsible for prioritisation across the range of programmes and healthcare services.
The Associate Director Clinical Programmes will provide routine updates to the committee on the progress with the work of the clinical programme groups (CPGs).
The CPG clinical leads will provide information and updates on individual programmes on an ad hoc basis as required.
The Associate Director of strategic Planning will provide regular updates to the committee on progress with specific projects and programmes initiated by the CCG.
Quorum Chair or Vice Chair, 3 CCG GPs, a Governing Body Lay Member, Accountable Officer or Deputy; Chief Financial Officer or deputy; Executive Nurse or Deputy.
Frequency of CCG Priorities Committee A minimum of 4 meetings per annum
Sub-groups All Clinical Programme Groups will formally report to the CCG Priorities Committee.
Secretariat to be provided by The Director of Transformation and Service Re-design team
Agenda and papers: The agenda and papers will be circulated electronically one week prior to the meeting. Agenda items and relevant papers should be submitted at least 1 week prior to this date.
Minutes will be circulated in draft within 5 working days of the meeting to allow members to respond.
Review: These terms of reference will be reviewed annually
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Appendix O
NHS Gloucestershire Clinical Commissioning Group
Primary Care Commissioning Committee Terms of Reference
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Introduction 1. NHS England has delegated authority to the Gloucestershire CCG (GCCG) for the commissioning of primary care as set out in Schedule 2 in accordance with section 13Z of the NHS Act. The detail of the powers of delegation is due to be published by NHS England in January 2015.
2. The GCCG acknowledges that, in addition to the statutory duties set out in Chapter A2 of the NHS Act that it already complies with, it must comply with the following as regards primary care: a) Duty to have regard to impact on services in certain areas (section13O);
b) Duty as respects variation in provision of health services (section 13P).
3. The GCCG has established the Primary Care Commissioning Committee (Committee) as a committee of the GCCG Governing Body, in accordance with Schedule 1A of the “NHS Act,” to manage primary care.
4. The members of the GCCG acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.
Aim of the Primary Care Commissioning Committee
5. The purpose of the Committee is to manage the delivery those elements of the primary care healthcare services delegated by NHS England to the GCCG working within the context of the overall CCG Plan. The aim will be to deliver to the people of Gloucestershire, on behalf of the GCCG, services that are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements.
Membership
6. The Committee shall consist of the following seven voting members, with actual membership included at Schedule 3:
Lay Chair
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Lay Member Accountable Officer Chief Finance Officer Executive Nurse and Quality Lead Governing Body Registered Nurse GCCG Governing Body GP
7. The Chair of the Committee shall be appointed from the existing Governing Body three lay members, but will exclude the Audit Committee Chair for reasons of good governance and probity. This appointment will be made by the Governing Body.
8. The Vice Chair of the Committee shall be the other lay member or the Governing Body Registered Nurse.
9. The Committee will invite the following as non-voting attendees: A HealthWatch representative A Health and Wellbeing Board representative NHS England Area Team
10. The Committee may invite any person to attend meetings to provide advice and/or expertise as required.
Secretary
11. The Committee secretary shall be the Associate Director of Corporate Governance.
Quorum
12. Five members of the Committee must be present for the quorum to be established including: at least two individuals being the lay members or the Governing Body Registered Nurse; and the Accountable Officer or the Chief Finance Officer
Meetings and Voting 13. The Committee will operate in accordance with the GCCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of meetings. This will
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be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 days before the date of the meeting.
14. The Committee shall meet bi-monthly.
15. The Chair of the Committee may convene additional meetings as required.
16. 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.
17. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution
18. 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.
19. The minutes of the Committee meetings shall be circulated by the Chair as soon as is practicable after the meetings to which they relate to all members of the Committee.
20. Meetings of the Committee shall:
a. be held in public;
b. the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.
Remit and responsibilities of the Committee
21. 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.
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22. 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 Gloucestershire CCG. This includes delegated responsibility for the following working within the context of the CCG Strategy:
a. The award of GMS, PMS and APMS contracts. This includes: the design of PMS and APMS contracts; and monitoring of contracts;
b. Locally defined and designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);
c. Making decision regarding local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);
d. Procurement of new practice provision;
e. Discretionary payment (e.g., returner/retainer schemes);
f. Reporting details of 22a –e to the Governing Body.
23. The Committee shall report on and make recommendations to the Governing Body on the following:
a. Primary medical care strategy for Gloucestershire;
b. Planning primary medical care services in Gloucestershire (including needs assessment);
c. Primary Care Estates Strategy;
d. Premises improvement grants and capital developments;
e. Contractual action such as issuing branch/remedial notices, and removing a contract;
f. Practice mergers.
24. The Committee may delegate some tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent
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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. The Committee may not delegate the procurement of services to any individual or sub-committee.
Financial Accountability
25. The Committee’s authority for procuring services is covered in the GCCG’s scheme of delegation and financial instructions.
Relationship with the Governing Body and Sub-Committees
Relationship with the Governing Body
26. The Committee has delegated authority for the commissioning of some primary care services as outlined in para 22a-e.
27. The Committee shall make recommendations to the Governing Body for the primary care services and functions listed at para 23a-f.
28. The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body. The Chair of the Committee shall report the outcome and recommendations of the committee to the next available Governing Body meeting.
Relationship with Sub-Committees
29. The NHS Gloucestershire Primary Care Operational Group (PCOG) shall undertake the operational management, implementation and oversight of the nationally defined primary care contracts and the primary care workstreams. In addition the PCOG will also monitor complaints and quality.
30. The Primary Care Operational Group sub-committee shall report to the Committee and submit the minutes of their meetings to the Committee for review.
Policy and best practice
31. The Committee shall have regard to current good practice, policies and guidance by the National Commissioning Board, GCCG and other relevant bodies.
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32. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.
Conduct of the Committee
33. The Committee shall conduct its business in an open and responsive manner and in accordance with these terms of reference and the GCCG’s governance arrangements.
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Appendix P
Locality Executive Group
TERMS OF REFERENCE
1. Purpose
To provide leadership for developing and implementing clinical commissioning plans at a locality level through the engagement of all practices and other stakeholders in the locality.
2. Objectives
. Fully engage in the clinical commissioning process.
. Work within the financial resources available each year (as set out through the indicative budget allocation)
. Ensure good communication regarding clinical commissioning between and within practices/localities, including dissemination of new care pathways and sharing of best practice.
. Work with the Gloucestershire Clinical Commissioning Group to ensure achievement of its strategic aims.
. Clearly articulate GCCG aspirations and objectives to constituent practices through locality plans.
. Work with Public Health colleagues to respond to the JSNA in order to improve outcomes and address health inequalities.
. Work with the GCCG to ensure PBC supports and enhances the quality, innovation, productivity and prevention (QIPP) agenda.
. Engage and involve patients and/or carers in GCCG developments and service redesign.
. Promote multi-professional involvement within locality clinical commissioning arrangements/structures.
. Feed into contract development to support the contract negotiations with providers e.g. quality, new care pathways.
. Lead service redesign/development and movement of services from secondary to community and primary care settings.
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3. Membership
Nominated Executive GPs from constituent practices Practice manager AHP / other clinical representative Patient representative
Commissioning Director/Executive team lead Medicines Management Finance and Information Public Health Other as required
4. Structure and Frequency of Meetings
The group will be chaired by a locality GP (as agreed by the GP members of the group).
The Chair will ensure that all communications relating to formal meetings are disseminated and papers / reports are circulated in a timely manner.
Agenda items should be forwarded to the Chair a minimum of one week prior to the meeting.
Formal meetings of the Executive will take place on a monthly basis.
5. Responsibility and Accountability
GP Executive members are responsible for ensuring that constituent practices are engaged in agreement and delivery of PBC plans.
GP Executive members are responsible for ensuring communication with the GP members on the Clinical Commissioning Group Governing Body.
Members will be responsible for ensuring that their own organisation or group is fully briefed on all key issues and decisions.
6. Governance and reporting
Governance arrangements are as set out in the PBC Agreement. The Executive Group is responsible for delivering the requirements of the agreement at locality level.
Reporting is to the Clinical Commissioning Group Governing Body and onwards to NHSG Board. The Locality will report to the Clinical Commissioning Group Shadow Board quarterly.
Papers and minutes are to be shared with all constituent GPs and practice managers, and the Clinical Commissioning Group Governing Body and be available to the public on request.
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7. Review of Terms of Reference
These Terms of Reference will be reviewed annually.
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Appendix QH
Clinical Commissioning Gloucestershire and Member Practices
Memorandum of Understanding
1. Memorandum of Understanding
1.1 The Memorandum of Understanding is between individual member practices and CCG and clarifies the expectations and obligations of both parties. It is designed to encourage productive and supportive engagement between the CCG and its Member Practices.
1.2 The Memorandum of Understanding documents the commissioning agreements reached between the member practice and CCG and will be the formal mechanism for determining eligibility to any future incentive payment (currently referred to as the Quality Premium). Accordingly it will be updated on an annual basis.
2. Parties to the Agreement
2.1 This Memorandum of Understanding is between the following parties;
Clinical Commissioning Gloucestershire (CCG) and its Member Practices.
3. Mission, Values and Aims of the CCG
3.1 Mission
3.1.1 The mission of CCG is to commission excellent and modern health services on behalf of the NHS for all people in Gloucestershire through effective clinical leadership, with particular focus on clinical effectiveness, patient safety and continuous improvements in the patient experience.
3.1.2 The group will promote good governance and proper stewardship of public resources in pursuance of its goals and in meeting its statutory duties.
3.2 Values and Aims
3.2.1 Good corporate governance arrangements are critical to achieving the group’s objectives.
3.2.2 The values/aims that lie at the heart of the group’s work are to:
. Ensure effective communication and engagement with clinicians, patients, carers, community partners and the public.
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. Use our clinical experience to ensure high quality, safe and efficient services for the people of Gloucestershire; . Focus on clinical benefit and health outcomes – making best use of the money and resources available; . Use our clinical experience to lead innovation and change – right care, right place, right time; . Be accountable and transparent in our decision making
4. Commissioning responsibilities of Member Practices Practice Representatives
4.1 Practice Representatives
4.1.1 Practice representatives represent their practice’s views and act on behalf of the practice in matters relating to the group. The role of each practice is to:
. Nominate commissioning and prescribing leads to:
a) represent the practice at CCG/locality meetings; and b) represent the needs of the practice’s patient population within the CCG;
. Actively engage with CCG to help improve services within the area and support effective commissioning by contributing to the development of commissioning intentions and contract development and review.
. Share all information and data, including referral, prescribing and admissions data, as appropriate, that relates to CCG’s commissioning priorities of delivering equitable quality care.
. Be familiar with the Clinical Programme Group approach, and follow the clinical pathways and referral protocols where defined and agreed by CCG (except in individual cases where there are justified clinical reasons for not doing this) which are fed back appropriately;
. Manage the practice’s commissioning and prescribing budget within allocated resources within the context of the risk share agreements agreed by the CCG. Support and assistance will continue to be provided to help member practices achieve this in the form of information and analysis, management support and specialist advice and support in areas such as prescribing.
. Participate in developing, as well as delivering the clinical, quality, safety effectiveness (and cost effective) strategies agreed by CCG and GH&WB (recognising the impact of such will have been assessed by the CCG).
. Promote the establishment of a practice reference group and other means determined, to obtain the views and experiences of patients and carers;
. Work constructively with the locality sub-committee/CCG;
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. Respond in a timely manner to reasonable commissioning-related information requests from CCG.
4.2 Locality Groups
4.2.1 The county-wide clinical commissioning group will comprise seven constituent localities. Each Locality will have an appointed Locality Lead and Executive team. Each Locality will also have an elected Locality Liaison Lead who will act as a conduit for the views of the locality as a part of their role as a member of the CCG Governing Body. Each locality will hold regular executive meetings as well as regular meetings involving the commissioning leads from each constituent practice. Such meetings will be in addition to other regular development sessions including Practice Learning Time and other locality-specific project groups.
4.2.2 The seven Locality groups are;
. Cheltenham; . Forest of Dean; . Gloucester City; . North Cotswolds; . South Cotswolds; . Stroud & Berkeley Vale; . Tewkesbury.
4.3 Structure and Frequency of Meetings
4.3.1 The group will meet regularly and be chaired by a locality GP (as agreed by the GP members of the group).
4.4 Practice Budgets
4.4.1 The full scope of the commissioning budget and detail of locality and practice level commissioning budgets and risk share agreements will be issued annually to practices for agreement.
4.5 Governance and reporting
4.5.1 Governance arrangements are as set out in the Locality Commissioning Agreement for 2012/13. Member Practices and their Executive Groups are responsible for delivering the requirements of the agreement at locality level.
4.5.2 Reporting is to the Clinical Commissioning Group Board. The locality will report to the Clinical Commissioning Group Board on a quarterly basis via their lead GP.
4.5.3 Locality group papers and minutes are to be shared with all constituent GPs and practice managers, and the Clinical Commissioning Group Board and be available to the public on request.
5. CCG responsibility to the development of a Member Organisation
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5.1 A key part of CCG’s commitment is to build CCG as a ‘membership organisation’.
5.2 CCG membership currently comprises 85 practices from seven constituent localities. Each locality appoints GPs or other healthcare professionals in the constituent practices to lead and chair the locality. Each locality will also have an elected Locality Liaison Lead who will be a member of the Governing Body of the CCG. Each Locality Liaison Lead will hold regular meetings involving the Commissioning Leads from each constituent practice of the locality.
5.3. CCG Role will be to:
. Set a commissioning strategy and policy (which is responsive to the needs assessment and priorities for the population and reflects the views of individual localities).
. Implement a clinical strategy using a co-production approach with the localities and defining quality outcomes and best value that meets the needs of our population.
. Provide a clinical leadership role by engaging member practices and the wider clinical community.
. Establish governance arrangements that establish CCG as a membership organisation.
. Establish and lead a clinical programme-based approach to commissioning.
. Ensure transparency and accountability in its decision making processes.
. Manage the commissioning budgets devolved to it.
. Support locality inspired projects where agreed and prioritised with CCG (with financial and management support) and where appropriate hold localities and others to account for their delivery.
6. Annual Commissioning Objectives
6.1 CCG will set annual commissioning objectives and targets that are outcome based and can demonstrate an improvement in the health of the local population. These will be agreed through the development of annual commissioning objectives/targets with each locality group.
7. Review of the Agreement
7.1 The agreement will be reviewed annually by CCG; any proposed changes will go to member practices for discussion prior to agreement.
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8. Signatories to the Agreement
Member Practice Name:
Member Practice signatory:
Chair of the CCG:
Date:
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Clinical Commissioning Gloucestershire
Disputes Resolution Process
1 Purpose
This paper outlines the approach Clinical Commissioning Gloucestershire (CCG) will adopt to address concerns/disputes raised by member practices in any of the following areas: . The CCG’s approach to the delivery of its commissioning responsibilities; . The commissioning responsibilities of member practices; . The CCG’s approach to delivery of its duty to support the NHS Commissioning Board in continuously improving the quality of primary care services.
2 Background
It is expected that use of the dispute resolution process will be the last resort. The CCG, its constituent localities and practices will make all efforts to resolve issues locally in conjunction with the LMC (as appropriate), and demonstrate effective processes have been engaged at all levels in the CCG. This may include the following involvement in informal resolution processes:
. Escalating the seniority of staff involved in any dispute, for example by involving the Chair/Deputy Clinical Chair or Chief Officer/Deputy Chief Officer. . Involving third parties who could also act as advisors, conciliators or arbitrators. . Using staff from another CCG.
Where agreement cannot be reached using informal resolution processes it will be necessary to invoke the local CCG resolution process outlined below.
3 Local Resolution Process
3.1 Stage 1 Informal Process:
Individual member practice concerns should be raised in the first instance with the CCG Locality Liaison Lead GP. This should be in writing clearly stating the basis of the dispute, including where applicable the concerns and the rationale behind the dispute.
The CCG Locality Liaison Lead GP should endeavour to find an informal resolution to the problem through discussion and mediation, involving others as necessary. The CCG Liaison Lead GP will review concerns/evidence relative to the dispute and will try to find a resolution within 14 days.
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The member practice may submit evidence in support of the dispute or the CCG may request further evidence/clarification from them.
If no resolution is found within 14 days the matter is to be referred by either party for consideration by the Local Dispute Resolution Panel.
At this stage the formal process will commence.
3.2 Stage 2 The Formal Local Process:
If a member practice is not satisfied that their issues have been satisfactorily addressed through the informal process they may lodge a request for “Formal Local Dispute Resolution” in writing, including the grounds for the request, to the Deputy Clinical Chair of the CCG. Under these circumstances the CCG will set up a Local Dispute Resolution Panel (LDRP) to hear the dispute and resolve the dispute where possible.
The local dispute panel should consist of:
. Governing Body lay member (Chair). . Deputy Clinical Chair. . CCG Locality Liaison Lead GP from a different locality from the practice. . Deputy Chief Officer OR Chief Financial Officer OR Director of Transformation and Service Re-Design. . LMC Representative.
The panel may also seek advice from external bodies such as the Local Area Team of the NHS Commissioning Board.
Should any members of the LDRP find it necessary to declare an interest in a dispute that is being considered, the Chair will approach another CCG representative to secure alternative panel members from within that CCG. In the event that this approach is unsuccessful other CCGs will be approached until a suitable alternative panel member from another CCG can be secured. If a member practice requests a formal dispute resolution, the CCG shall acknowledge receipt of the request in writing within 2 working days. The acknowledgement will explain the procedure to be carried out by the CCG.
The Hearing
The Chair of the LDRP, on being satisfied that all attempts at local resolution have been exhausted will arrange a meeting of the LDRP to hear the dispute as soon is practically possible. All parties shall be notified of the date and time of the LDRP meeting. The hearing shall be held within 25 working days of the request being lodged (where possible) by the member practice to the CCG. The Chair of the LDRP will ensure that at least 10 working days’ notice of the date of the hearing will be given to all participants.
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Documentation
All the relevant documentation, including the request for Formal Local Dispute Resolution will be passed to the chair and then to panel members before the hearing. The Chair will, where necessary, seek relevant documentation from the parties involved at least 5 working days before the hearing. Documentation that is received late will not be considered. Any documentation will be shared with all relevant panel members.
Procedure at LDRP Meeting
. The Discussions of the panel shall remain confidential. . The Chair of the panel will ensure written record/minutes are kept of the meeting. . All written and verbal evidence will be considered. . Should the member practice choose to attend the LDRP they and the CCG presenting officer (generally the CCG Locality Liaison Lead GP) will be asked to present their cases and may call witnesses. Members of the panel will be given the opportunity to ask any questions relevant to the case. . Following the presentation of their case the member practice and CCG presenting officer shall withdraw and the panel will deliberate. . The panel will reach a decision on the case before them and notify the member practice in writing, including any recommendations within 7 working days of the hearing. . Where appropriate the decision will be reported to a meeting of the CCG Executive Team/Governing Body for information.
3.3 Stage 3 Appeal Panel
The Appeals panel will be convened when necessary to consider appeals against LDRP decisions. The Appeals panel should consist of the following (none of whom should have been previously involved in the case)
. Clinical Chair of another CCG. . A Clinical member of the Governing Body. . CCG Accountable Officer or Deputy . LMC Representative.
Process . The member practice wishing to appeal against a LDRP decision must notify the CCG Accountable Officer of their intention, in writing, within one month of their receipt of the decision. . The Appeals Panel will consider whether the original decision of the LDRP followed due process. . The Appeals Panel will only consider written evidence. . The Appeals Panel will consider if: o The CCG correctly followed its own procedures (all received documentation was available and considered within a reasonable timescale) and/or o All important facts were taken into account when the decision was made.
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. If these criteria are met the Panel will dismiss the appeal. . If the criteria are not met then the following actions are available: o If the Panel finds that some aspect of the procedure was not followed, they will assess the significance of the procedural breach and decide on the appropriate action. o If the Panel finds that important facts were not taken into account, they shall refer the case back to the original LDRP for re-consideration. . If the case is referred back to the LDRP following re-consideration of the case, the LDRP decision will then be final. . The Chair of the Appeal Panel will write to the member practice within five working days of the hearing setting out the Appeal Panel’s decision.
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Supporting documents to the Constitution
0
CONTENTS
Appendix Description Page A Detailed Scheme of Delegation 2 B Prime Financial Policies 39 C Terms of Reference Audit Committee 51 D Terms of Reference Remuneration Committee 58 E Terms of Reference Integrated Governance and Quality 61 Committee F Terms of Reference Priorities Committee 67 G Terms of Reference Primary Care Commissioning 70 Committee H Terms of Reference Locality Executive Group 77
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APPENDIX A – DETAILED SCHEME OF DELEGATION
The Detailed Delegated Limits outlined below represent the lowest level to which authority within the CCG is delegated
Delegation to lower levels or other offices is not permitted without the specific authority of in writing of the Accountable Officer or the Chief Finance Officer. All items concerning Finance must be carried out in accordance with Prime Financial Polices and Standing Orders.
Delegated authority may be exercised by a formally nominated deputy in the absence of the primary delegate.
In certain circumstances the limits of authorisation in this document may be temporarily amended. Such amendments will be communicated by the Accountable Officer or Chief Finance Officer using cascade e‐mails.
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 1. Management of Budgets ‐ Sec 7 Responsibility to keep expenditure within budgets and to ensure that budgets are only used for the type of expenditure for which they have been set.
At individual budget level (Pay and Non Budget Holder Pay)
At Directorate level Director
All Other Areas Chief Finance Officer/Accountable Officer
Prime Financial Policies 2. Maintenance/Operation of Bank Chief Finance Officer In accordance with PFP ‐ Sec 11 Accounts
a) Approval of banking arrangements
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
b) Variation to approved signatories Governing Body
Chief Finance Officer
Prime Financial Policies 3. Non Pay Revenue and Capital ‐ Sec 17 Expenditure / Requisitioning / Ordering
a) Payment of Goods and Services Stock/non‐stock requisitions up to £1,000 Budget Manager
Stock/non‐stock requisitions up to Budget Holder £10,000
Stock/non stock requisitions up to Directors £249,999
Stock/non stock requisitions from Chief Finance Officer £250,000 to £499,999
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
Stock/non stock requisitions from Accountable Officer £500,000 to £999,999
Stock/non stock requisitions from Governing Body £1,000,000
b) Authorisation of Payments against an Accountable Officer Chief signed NHS Contract or signed s75 or Finance Officer, s256 with the Local Authority Director, Deputy Director of Commissioning, Deputy CFO Prime Financial Policies f) Approval of Virements ‐ Sec 7 Between commissioning budgets up to Budget Holder £50,000 or between admin budgets/provider patient services non‐ recurrently up to £10,000
Between commissioning budgets up to Chief Finance Officer £100,000 or between admin budgets recurrently and/or up to £50,000
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Above £100,000 between Accountable Officer commissioning budgets or above £50,000 between admin budgets
g) Orders exceeding 36 month period Accountable Officer or Chief Finance Officer
h) All contracts for Non Health Care As section 3a goods & services and subsequent variations to contracts i) Prepayments over £1,500 Chief Finance Officer or Deputy CFO
Prime Financial Policies 4. Capital Schemes ‐ Sec 18 a) Delegated Limits for Capital Investment for buildings, PFI, IM&T and equipment investments, and property leases
Up to £35 million NHS England – subject to full business case approval
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner and following approval by Governing Body From £35 million and above Department of Health and HM Treasury Selection of Architects, quantity Accountable Officer or surveyors, consultant engineer and Chief Finance Officer other professional advisors within EU regulations
Financial monitoring and reporting Chief Finance Officer on all capital scheme expenditure Prime Financial 5.1 Quotation, Tender and & Contract Policies - Sec 13 Procedures (including secondary, primary and community healthcare services) where no suitable nationally negotiated framework agreements / contracts are available for use:
(Values are the total value of expenditure
excluding VAT for the total duration of
any time period committed to):
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
a) No requirement to obtain As per section 3 quotes for single items up to £1,000 As per section 3 b) 2 written quotes for goods / services between £1,000 and
£5,000.
As per section 3
c) Obtaining a minimum of 3 written quotations for goods / services from £5,000 to £50,000 As per section 3 d) Obtaining a minimum of 3 written competitive tenders for goods / services from £50,000 (process by delegated procurement personnel). Chief Finance Officer / e) Contracts above European Deputy CFO Union (OJEU) limits. Chief Finance Officer/
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner f) Approval to accept quote / Accountable Officer Report to Audit tender other than the lowest that Committee meet the award criteria Quotations & tenders <£99,999
Chief Finance Tenders >£100,000 Officer/Accountable Officer
g) Waiving of quotations & Tenders subject to SOs & PFP Chief Finance Officer Up to £99,999 Accountable Officer £100,000 ‐ £249,999 Governing Body £250,000+ Directors and Senior Opening Quotations: Manager
Accountable Officer and
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Opening Tenders: Directors, Deputy CFO, Associate Director of Corporate Governance
5.2. A Mini‐Competition* or Direct Call‐ Off* for goods or services of any value (including secondary, primary and community healthcare services) against a suitable nationally negotiated framework agreements / contracts:
*In accordance with framework terms and conditions of contract.
Up to £1,000 As per section 3
Between £1,000 and £5,000 As per section 3
From £50,000 As per section 3 Report to Audit Committee
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 6. Setting of Fees and Charges ‐ Sec 12 a) Private Patient, Overseas Visitors, Chief Finance Officer or Income Generation and other Deputy CFO patient related services
b) Price of NHS Contracts Chief Finance Officer or Deputy CFO
c) Price of Non NHS Contracts Chief Finance Officer or Deputy CFO 7. Income Collection
Cancellation of invoices incorrectly Chief Finance Officer or raised Deputy CFO Authority to pursue legal action for Chief Finance Officer or bad debts Deputy CFO Approval of write offs relating to over Chief Finance Officer payment of salary
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 8. Agreement and Signing of Contracts ‐ Sec 14 for the purchasing of Health Care and Agreements with the Local Authority and GP Practices
Signing of Health Care Contracts with the Local Authority Director of Commissioning Contracts of less than £10,000,000 Implementation or Chief Finance Officer
Accountable Officer or Contracts greater than Chief Finance Officer £10,000,000
Director of Commissioning Variations to contracts Implementation or Chief Finance Officer
Accountable Officer / Signing of Agreements between the CCG Chief Finance Officer or and the Local Authority Director of Commissioning
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Implementation
Signing of Agreements and Contracts for Accountable Officer or the purchase of primary care services Chief Finance Officer with GP practices.
Prime Financial Policies 9. Engagement of Staff Not On the ‐ Sec 7 Establishment
a) Non Medical Consultancy Staff Accountable Officer and or total commitment is Chief Finance Officer <£20,000 in one year where budget is available >£20,000 or where no budget available
b) Engagement of CCG’s Solicitors Associate Director of Corporate Governance
c) Booking of Bank or Agency Staff Budget Manager
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Prime Financial Policies 10. Expenditure on Charitable and Designated Fund ‐ Sec 20 Endowment Funds Managers in accordance with procedures and limits laid down for charitable funds by the corporate trustee 11. Agreements/Licences/Leases
a) Preparation of all tenancy Director responsible for agreements/licences for all staff Estates subject to CCG Policy on accommodation for staff
b) Initial review of all proposed lease Deputy CFO agreements to assess financial implications of lease agreement
c) Authorisation to sign leases/licences NHS England Signature of all tenancy agreements/licences (as above)
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner d) extensions to existing licences and Accountable Officer or leases Chief Finance Officer
e) Letting of premises to outside Chief Finance Officer organisations }
f) Approval of rent based on Chief Finance Officer professional assessment
Prime Financial Policies 12. Condemning & Disposal ‐ Sec 18 Maintain losses and special payments Chief Finance Officer register
a) Items obsolete, obsolescent, redundant, irreparable or cannot be required cost effectively
1) with current/estimated purchase Budget Manager price <£499
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 2) with current purchase new price Chief Finance Officer >£500+
3) Disposal of mechanical and Chief Finance Officer engineering plant (subject to estimated income exceeding £1,000 per sale)
b) Disposal of property or land Governing Body 13. Losses, Write –off & Compensation
a) Losses of cash due to:
1) Theft, Fraud, etc 2) Overpayments of Salaries, wages, fees & allowances 3) Other Causes including un‐vouched or incompletely vouched payments, overpayments other than those included under item 2: physical losses of cash and cash equivalents, e.g. stamps due to fire
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner (other than arson), accident and similar causes Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) b) Fruitless payments (including abandoned capital Schemes)
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 11/05) c) Bad debts and claims abandoned:‐
1) Private patients (Sect. 65/ 66 NHS Act 1977) 2) Overseas visitors (Sect. 121 NHS Act 1977) 3) Cases other than 1) – 2)
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) d) Damage to buildings, their fittings, furniture and equipment and loss of equipment and property in stores and in use due to:
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
1) Culpable causes e.g. theft, Chief Finance Officer fraud, arson or sabotage whether proved or suspected, neglect of duty or gross carelessness
2) Other causes Up to £10,000 Chief Finance Officer Up to 25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05) e) Compensation payments made under Governing Body legal obligation
f) Extra contractual payments to contractors
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05) g) Ex gratia payments to patients & staff for loss of personal effects
Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN)
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 11/05)
h) For clinical negligence (negotiated settlements following legal advice) where the guidance relating to such payments has been applied (including plaintiffs costs) Up to £10,000 Chief Finance Officer Up to £25,000 Accountable Officer Over £25,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05)
For Clinical negligence where the guidance relating to such payments has not been applied
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Up to £1,000 Chief Finance Officer Up to £5,000 Accountable Officer Over £5,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05)
i) For personal injury claims involving negligence where relevant guidance has been applied (including plaintiffs costs) Up to £1,000 Chief Finance Officer Up to £15,000 Accountable Officer Over £15,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05)
For personal injury claims involving negligence where legal advice obtained and relevant guidance has not been applied
Up to £1,000 Chief Finance Officer Up to £5,000 Accountable Officer Over £5,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH Special severance payments (Dear Accounting Officer letter DAO (GEN) HM Treasury 11/05)
j) Other clinical negligence cases & personal injury claims
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
Up to £1,000 Chief Finance Officer Up to £15,000 Accountable Officer Over £15,000 Governing Body
Novel, contentious or repercussive cases NHS England prior to submission to DH
Special severance payments (Dear HM Treasury Accounting Officer letter DAO (GEN) 11/05) k) Other, except cases of maladministration where there was no financial loss by claimant
All Governing Body 1) Others 2) Maladministration where there was no financial loss by claimant 3) Patient referrals outside the UK and EEA guidelines 4) Extra statutory and extra
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner regulationary payments
All Governing Body Prime Financial Policies 14. Reporting of Incidents to the Police ‐ Sec 4 a) Where a criminal offence is suspected Appropriate Manager
criminal offence of a violent nature other
b) Where a fraud is involved Chief Finance Officer or Accountable Officer Prime Financial Policies 15. Petty Cash Disbursements (not ‐ Sec 12 applicable to central Cashiers Office)
General Expenditure up to £25 per As determined by the item Chief Finance Officer
16. Receiving Hospitality
Applies to both individual and Declaration required in CCG Hospitality Register
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner collective hospitality In excess of £25.00 per item received Prime Financial Policies 17. Implementation of Internal and Budget Manager or ‐ Sec 3 External Audit Recommendations Director Prime Financial Policies 18. Maintenance & Update of CCG Chief Finance Officer ‐ Sec 2 Financial Procedures Prime Financial Policies 19. Personnel & Pay ‐ Sec 16 a) Authority to fill funded post on the Core Team establishment with permanent staff including the ability to alter skill mix within existing budget
b) Authority to appoint staff to post not Accountable Officer on the funded establishment
c) The granting of additional salary HR Lead and Relevant increments to staff within budget Director
d) All requests for upgrading or regrading shall be dealt with in accordance with
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner CCG Procedure
e) Establishments
1) Additional staff to the agreed Director with the Chief establishment with specifically Finance Officer allocated finance.
2) Additional staff to the agreed Accountable Officer and establishment without specifically Chief Finance Officer allocated finance f) Pay
a) Authority to complete standing HR Lead and Budget data forms effecting pay, new Manager starters, variations and leavers
b) Authority to complete and Budget Manager authorise positive reporting forms
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner
c) Authority to authorise overtime Budget Holder
d) Authority to authorise mileage Line Manager claims, subsistence expenses & exam fees
e) Submission of travel and Employee subsistence claims within 3 months of incurring expenditure
f) Authorisation of travel expenses Chief Finance Officer over 3 months old
g) Authorisation of non travel, Budget Manager Exceptional subsistence or exam fees through circumstances only, expenses claim form supplies procedure should be followed Approval of Performance Related Pay Line/Departmental Assessment Manager
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner g) Leave } } a) Approval of annual leave } b) Compassionate leave up to 3 days } As per CCG policy c) Compassionate leave up to 6 days } d) Special leave arrangements } Paternity leave } Carers leave 3/5 days } e) Leave without pay } f) Time off in lieu Line manager g) Maternity Leave _ paid and unpaid As per CCG policy h) Sick Leave Extensions of sick leave beyond Director in conjunction CCG terms and Conditions with HR Lead
Return to work part‐time on full Director in conjunction pay day to assist recovery in excess with HR Lead of CCG terms and conditions Extension of sick leave on full pay Accountable Officer or in excess of CCG terms and Chief Finance Officer and conditions HR Lead
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner i) Study Leave
Study leave outside the UK Accountable Officer All study leave (UK) in excess of CCG Accountable Officer or training procurement Director j) Removal Expenses, Excess Rent and House Purchases
Authorisation of payment of removal expenses in accordance with CCG policy incurred by officers taking up new appointments (providing consideration was promised at interview) Up to £5,000 Director Over £5,000 to £8,000 maximum Accountable Officer or Chief Finance Officer k) Grievance Procedure
All grievances cases must be dealt with HR Lead CCG Grievance strictly in accordance with the Grievance Procedure Procedure and the advice of the Human Resource Manager must be sought when
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner the grievance reaches the level of General Manager
l) Authorised Car & Mobile Phone Users
Requests for new posts to be Director and HR Lead authorised as car users Requests for existing post to be Director and HR Lead authorised as car users from the current financial year– standard, regular or lease car users Requests for existing post to be Chief Finance Officer authorised as car users from the prior to current financial year– standard, regular or lease car users Requests for new posts to be Director and HR Lead authorised as mobile telephone users m) Renewal of Fixed Term Contract Director
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner n) Redundancy Accountable Officer / Redeployment and Chief Finance Officer and Redundant policy HR Lead o) Ill Health Retirement
Decision to pursue retirement on the Chief Finance Officer and grounds of ill‐health HR Lead p) Dismissal Director or nominated Disciplinary policy deputy
Prime Financial Policies 20.Insurance Policies and Risk Accountable Officer / ‐ Sec 15 Managment Associate Director Corporate Governance 21. Patients’ & Relatives’ Complaints
a) Overall responsibility for ensuring Accountable Officer and that all complaints are dealt with Associate Director of effectively Patient and Public Involvement b) Responsibilty for ensuring complaints Accountable Officer and
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner relating to directorate are Associate Director of investigated thoroughly Patient and Public Involvement
c) Medico – Legal Complaints ‐ Co Accountable Officer and ordination of their managment Associate Director Corporate Governance 22. Relationships with Press
a) Non‐Emergency General Enquiries
Within Hours Communications Manager
Outside Hours Manager on call or Associate Director of Communications
b) Emergency
Within Hours Communications Manager
Outside Hours Manager on call or
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Associate Director of Communications 23. Infectious Diseases & Notifiable Manager on call or Health Outbreaks Protection Unit Contact or Director of Public Health 24.Facilities for staff not employed by the CCG to gain practical experience Professional Recognition, Honary Contracts, & Insurance of Medical HR Lead Staff Work experience students HR Lead
25. Review of Fire Precautions Director responsible for Health & Safety 26.Review of all statutory compliance Director responsible for legislaton and Health and Safety Health & Safety requirements including control of Substances Hazardous to Health Regulations
27. Review of Medicines Inspectorate Head of Medicines
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Regulations Management
28. Review of compliance with Director responsible for environmental regulations, for Estates example those relating to clean air and waste disposal 29. Review of CCG’s compliance with the Chief Finance Officer Data Protection Act 30. Monitor proposals for contractual Appropriate Director arrangments between the CCG and the outside bodies
31. Review the CCG’s compliance with Chief Finance Officer the Access to Records Act
32. Review of the CCG’s compliance Chief Finance Officer Code of Practice for handling confidential information in the contracting environment and the compliance with “safe Haven” per EL 92/60
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner 33. The keeping of a Declaration of Interests Register (a) Board and Executive Committee Associate Director of Members Corporate Governance (b) Staff members Associate Director of Corporate Governance 34. Attestation of sealings in accordance Chair, Accountable Officer with Standing Orders or Chief Finance Officer (a) custody (b) register of sealings 35. The keeping of the register of Accountable Officer Sealings
36. The keeping of the Hospitality Accountable Officer Register
Prime Financial Policies 37. Retention of Records Associate Director of – Sec 19 Corporate Governance
38. Security Management Director responsible for Local Security 39. Contractor’s Responsibilities
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Reference Document Delegated Matter Delegated Authority ‐ Scope of Delegation Commissioner Ensuring contractors and their All employees employees are aware of any requirement to comply with Standing Orders and Prime Financial Policies
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SUMMARY OF KEY RESPONSIBILITIES OF ALL EMPLOYEES UNDER STANDING ORDERS AND PRIME FINANCIAL POLICIES
Responsibility: Of To comply with all procedures implemented by the All employees Governing Body, Accountable Officer or Chief Financial Officer to ensure compliance with Standing Orders and Prime Financial Policies To report instances of non‐compliance with Standing All employees Orders and Prime Financial Policies To act in such a way as to maintain the security of all All employees CCG property To report losses immediately to the Chief Financial All employees Officer following the process laid down To inform the Chief Financial Officer following the All employees process laid down of any income due to the CCG in respect of their area of responsibility To inform the appropriate person, in accordance with All employees the guidance and options laid down, of any suspicion of fraud or corruption To declare in accordance with the procedures laid All employees down, any gifts or hospitality or sponsorship received To declare in accordance with the procedures laid All employees down any interests which may conflict with fulfilment of their role To comply with the Standards of Business Conduct All employees for NHS Staff To set in place arrangements to maintain the security Senior managers of all CCG property within their area of responsibility To comply with the Code of Conduct for NHS Senior Managers Managers To comply with Protocol for Avoidance of Potential All staff as Conflicts of Interest and Potential Unfair Competitive appropriate Advantage.
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APPENDIX B - PRIME FINANCIAL POLICIES
1. INTRODUCTION
1.1. General
1.1.1. These Prime Financial Policies and supporting Detailed Financial Procedures shall have effect as if incorporated into the Group’s Constitution.
1.1.2. The Prime Financial Policies are part of the Group’s control environment for managing the organisation’s financial affairs. They contribute to good corporate governance, internal control and managing risks. They enable sound administration, lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Accountable Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the Scheme of Reservation and Delegation found at Appendix D.
1.1.3. In support of these Prime Financial Policies, the Governing Body has prepared more detailed procedures, approved by the Chief Finance Officer known as detailed financial procedures. The Group refers to these Prime Financial Policies and Detailed Financial Procedures together as the Clinical Commissioning Group’s financial policies.
1.1.4. These Prime Financial Policies identify the financial responsibilities which apply to everyone working for the Group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the Detailed Financial Procedures. The Chief Finance Officer is responsible for approving all Detailed Financial Procedures.
1.1.5. A list of the Clinical Commissioning Group’s Detailed Financial Procedures will be published and maintained on the Group’s website. Documentation will also be available upon request for inspection at:
Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucestershire GL3 4FE
1.1.6. Should any difficulties arise regarding the interpretation or application of any of the Prime Financial Policies then the advice of the Chief Finance Officer must be sought before acting. The user of these Prime Financial Policies should also be familiar with and comply with the provisions of the Group’s Constitution, Standing Orders and Scheme of Reservation and Delegation.
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1.1.7 Failure to comply with Prime Financial Policies and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.
1.2. Overriding Prime Financial Policies
1.2.1. If for any reason these Prime Financial Policies 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’s Audit Committee for referring action or ratification. All of the Group’s members and employees have a duty to disclose any non-compliance with these Prime Financial Policies to the Chief Finance Officer as soon as possible.
1.3. Responsibilities and delegation
1.3.1. The roles and responsibilities of the Group’s members, employees, members of the Governing Body, members of the Governing Body’s committees and sub- committees, members of the Group’s committee and sub-committee (if any) and persons working on behalf of the Group are set out in chapters 6 and 7 of this Constitution.
1.3.2. All Governing Body members and employees who carry out a financial function must keep financial records and discharge their duties in a manner that is satisfactory to the Chief Finance Officer
1.3.3. The financial decisions delegated by members of the Governing Body are set out in the Group’s Scheme of Reservation and Delegation (see Appendix D).
1.4. Contractors and their employees
1.4.1. Any contractor or employee of a contractor who is empowered by the Group to commit the Group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Accountable Officer to ensure that such persons are made aware of this.
1.5. Amendment of Prime Financial Policies
1.5.1. To ensure that these Prime Financial Policies remain up-to-date and relevant, the Chief Finance Officer will review them at least annually. Following consultation with the Accountable Officer and scrutiny by the Governing Body’s Audit Committee, the Chief Finance Officer will recommend amendments, as fitting, to the Governing Body for approval. As these Prime Financial Policies are an integral part of the Group’s Constitution, any amendment will not come into force until the Group applies to NHS England and that application is granted.
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2. INTERNAL CONTROL
POLICY – the Group will put in place a suitable control environment and effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies.
2.1. The Governing Body is required to establish an Audit Committee with terms of reference agreed by the Governing Body (see paragraph 6.6.6 (a) of the Group’s Constitution for further information).
2.2. The Accountable Officer has overall responsibility for the Group’s systems of internal control.
2.3. The Chief Finance Officer will ensure that:
a) financial policies are considered for review and update annually;
b) a system is in place for proper checking and reporting of all breaches of financial policies; and
c) a proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.
3. AUDIT
POLICY – the Group will keep an effective and independent internal audit function and fully comply with the requirements of external audit and other statutory reviews.
3.1. In line with the terms of reference for the Governing Body’s Audit Committee, the person appointed by the Group to be responsible for internal audit and the Audit Commission appointed external auditor will have direct and unrestricted access to Audit Committee members and the Chair of the Governing Body, Accountable Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.
3.2. The person appointed by the Group to be responsible for internal audit and the external auditor will have access to the Audit Committee and the Accountable Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the Governing Body and the Accountable Officer will have direct and unrestricted access to the head of internal audit and external auditors.
3.3. The Chief Finance Officer will ensure that:
a) the Group has a professional and technically competent internal audit function; and
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b) the Governing Body approves any changes to the provision or delivery of assurance services to the Group.
3.4. The Chief Finance Officer or designated internal or external auditor is entitled, without necessarily giving prior notice, to require and receive:
a) Access to all records, documents and correspondence relating to any financial or other relevant transactions including documents of a confidential nature with regards to the business of the Clinical Commissioning Group.
b) Access at all reasonable times to any land, premises or property of the Clinical Commissioning Group.
c) Explanations concerning any matter under investigation.
4. FRAUD AND CORRUPTION
POLICY – the Group requires all staff to always act honestly and with integrity to safeguard the public resources they are responsible for. The group will not tolerate any fraud perpetrated against it and will actively chase any loss suffered.
4.1. The Governing Body’s Audit Committee will satisfy itself that the Group 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.
4.2. The Governing Body’s Audit Committee will ensure that the Group has arrangements in place to work effectively with NHS Protect.
5. EXPENDITURE CONTROL
5.1. The Group is required by statutory provisions1 to ensure that its expenditure does not exceed the aggregate of allotments from NHS England and any other sums it has received and is legally allowed to spend.
5.2. The Accountable Officer has overall executive responsibility for ensuring that the Group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.
5.3. The Chief Finance Officer will:
a) provide reports to NHS England in the form required by NHS England;
b) report the financial position of the Clinical Commissioning Group to the Governing Body.
1 See section 223H of the 2006 Act, inserted by section 27 of the 2012 Act
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c) ensure money drawn from NHS England is required for approved expenditure only is drawn down only at the time of need and follows best practice;
d) be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the group to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of NHS England.
6. ALLOTMENTS2
6.1. The Group’s Chief Finance Officer will:
a) periodically review the basis and assumptions used by NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the Group’s entitlement to funds;
b) prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and
c) regularly update the Governing Body on significant changes to the initial allocation and the uses of such funds.
7. COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING
POLICY – the Group will produce and publish an annual operating plan which spans the medium term (i.e. the current and next financial years) and includes reference to the QIPP programme and commissioning intentions, and that explains how the Group proposes to discharge its financial duties. The group will support this with comprehensive medium-term financial plans and annual budgets.
7.1. The Accountable Officer will compile and submit to the Governing Body a commissioning strategy which takes into account financial targets and forecast limits of available resources.
7.2. Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Accountable Officer, prepare and submit budgets for approval by the Governing Body.
7.3. The Chief Financial Officer shall monitor financial performance against budget and plan, periodically review them, and report to the Governing Body. This report should include explanations for variances. These variances must be based on any significant departures from agreed financial plans or budgets.
2 See section 223(G) of the 2006 Act, inserted by section 27 of the 2012 Act.
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7.4. Financial monitoring information will also incorporate an assessment of the forecast outturn position based on levels of expenditure being incurred and the risks to non-achievement of the plan.
7.5. The Accountable Officer is responsible for ensuring that information relating to the Group’s accounts or to its income or expenditure, or its use of resources is provided to NHS England as requested.
7.6. The Governing Body will approve consultation arrangements for the Group’s commissioning strategy3.
8. ANNUAL ACCOUNTS AND REPORTS
POLICY – the Group will produce and submit to NHS England accounts and reports in accordance with all statutory obligations4, relevant accounting standards and accounting best practice in the form and content and at the time required by NHS England.
8.1. The Chief Finance Officer will ensure the Group:
a) prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the Governing Body;
b) prepares the accounts according to the timetable approved by the Governing Body;
c) complies with statutory requirements and relevant directions for the publication of annual report;
d) considers the external auditor’s management letter and fully addresses all issues within agreed timescales; and
e) publishes the external auditor’s management letter on the Group’s website.. Documentation will be available upon request for inspection at:
Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucestershire GL3 4FE
3 See section 14Z13 of the 2006 Act, inserted by section 26 of the 2012 Act 4 See paragraph 17 of Schedule 1A of the 2006 Act, as inserted by Schedule 2 of the 2012 Act.
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9. INFORMATION TECHNOLOGY
POLICY – the group will ensure the accuracy and security of the group’s computerised financial data.
9.1. The Chief Finance Officer is responsible for the accuracy and security of the Group’s computerised financial data and shall:
a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Group's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;
b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;
c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;
d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Chief Finance Officer may consider necessary are being carried out.
9.2. In addition the Chief Finance Officer shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.
10. ACCOUNTING SYSTEMS
POLICY – the Group will run an accounting system that creates management and financial accounts.
10.1. The Chief Finance Officer will ensure:
a) the Group has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of NHS England;
b) that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
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10.2. Where another health organisation or any other agency provides a computer service for financial applications, the Chief Finance Officer shall periodically seek assurances that adequate controls are in operation.
11. BANK ACCOUNTS
POLICY – the Group will keep enough liquidity to meet its current commitments.
11.1. The Chief Finance Officer will:
a) review the banking arrangements of the Group at regular intervals to ensure they are in accordance with Secretary of State directions5, best practice and represent best value for money;
b) manage the Group's banking arrangements and advise the Group on the provision of banking services and operation of accounts;
c) prepare detailed instructions on the operation of bank accounts.
11.2. The Accountable Officer shall approve the banking arrangements.
12. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS.
POLICY – the Group will: . operate a sound system for prompt recording, invoicing and collection of all monies due; . seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the group or its functions;6 . ensure its power to make grants and loans is used to discharge its functions effectively.7
12.1. The Chief Financial Officer is responsible for:
a) designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due;
b) establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;
c) approving and regularly reviewing the level of all fees and charges other than those determined by NHS England or by statute. Independent professional advice on matters of valuation shall be taken as necessary;
5 See section 223H(3) of the NHS Act 2006, inserted by section 27 of the 2012 Act 6 See section 14Z5 of the 2006 Act, inserted by section 26 of the 2012 Act. 7 See section 14Z6 of the 2006 Act, inserted by section 26 of the 2012 Act.
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d) developing effective arrangements for making grants or loans.
13. TENDERING AND CONTRACTING PROCEDURE
POLICY – the Group: . will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending; . will seek value for money for all goods and services; . shall ensure that competitive tenders are invited for . the supply of goods, materials and manufactured articles; . the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health); and . for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals.
13.1. The Group shall ensure that the firms / individuals invited to tender (and where appropriate, quote) are among those on approved lists or where necessary a framework agreement. Where in the opinion of the Chief Finance Officer it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Accountable Officer or the Group’s Governing Body.
13.2. The Governing Body may only negotiate contracts on behalf of the Group, and the Group may only enter into contracts, within the statutory framework set up by the 2006 Act, as amended by the 2012 Act. Such contracts shall comply with:
a) the Group’s Standing Orders;
b) the Public Contracts Regulation 2006, any successor legislation and any other applicable law; and
c) take into account as appropriate any applicable NHS England or the Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (b) above.
13.3. In all contracts entered into, the Group shall endeavour to obtain best value for money. The Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group.
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14. COMMISSIONING
POLICY – working in partnership with relevant national and local stakeholders, the Group will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility.
14.1. The Group will coordinate its work with NHS England, other clinical commissioning groups, local providers of services, local authority(ies), including through Health & Wellbeing Boards, patients and their carers and the voluntary sector and others as appropriate to develop robust commissioning plans.
14.2. The Accountable Officer will establish arrangements to ensure that regular reports are provided to the Governing Body detailing actual and forecast expenditure and activity for each contract.
14.3. The Chief Finance Officer will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.
15. RISK MANAGEMENT AND INSURANCE
POLICY – the Group will put arrangements in place for evaluation and management of its risks.
15.1. The CCG will adopt a Risk Management Strategy that will outline the organisation’s approach to managing risk. A key feature of the strategy will be the maintenance of a Risk Register that will be used to record and monitor risks. It is intended that the Risk Register will be presented to each meeting of the Integrated Governance and Quality Committee to provide on-going oversight and review.
15.2. An Assurance Framework will also be maintained to provide details of the assurances that will be provided to the Governing Body regarding the achievement of the organisation’s Annual Objectives. The Assurance Framework will identify gaps in assurances and controls regarding the objectives, along with details of the major risks that have been identified. The Assurance Framework will also be presented to each meeting of the Integrated Governance and Quality Committee as part of the oversight and review activity.
16. PAYROLL
POLICY – the Group will put arrangements in place for an effective payroll service.
16.1. The Chief Finance Officer will ensure that the payroll service selected:
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a) is supported by appropriate (i.e. contracted) terms and conditions;
b) has adequate internal controls and audit review processes;
c) has suitable arrangements for the collection of payroll deductions and payment of these to appropriate bodies.
16.2. In addition the Chief Finance Officer shall set out comprehensive procedures for the effective processing of payroll.
17. NON-PAY EXPENDITURE
POLICY – the Group will seek to obtain the best value for money goods and services received.
17.1. The Governing Body will approve the level of non-pay expenditure on an annual basis and the Accountable Officer will determine the level of delegation to budget managers.
17.2. The Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services.
17.3. The Chief Finance Officer will:
a) advise the Accountable Officer on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the scheme of reservation and delegation;
b) be responsible for the prompt payment of all properly authorised accounts and claims;
c) be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable.
18. CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS
POLICY – the Group will put arrangements in place to manage capital investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the Group’s fixed assets.
18.1. The Accountable Officer will:
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a) ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;
b) be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;
c) shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges;
d) be responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.
18.2. The Chief Finance Officer will prepare detailed procedures for the disposals of assets.
19. RETENTION OF RECORDS
POLICY – the Group will put arrangements in place to retain all records in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance.
19.1. The Accountable Officer shall:
a) be responsible for maintaining all records required to be retained in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance;
b) ensure that arrangements are in place for effective responses to Freedom of Information requests;
c) publish and maintain a Freedom of Information Publication Scheme.
20. TRUST FUNDS AND TRUSTEES
POLICY – the Group will put arrangements in place to provide for the appointment of trustees if the group holds property on trust.
20.1. The Chief Finance Officer shall ensure that each trust fund which the Group is responsible for managing is managed appropriately with regard to its purpose and to its requirements.
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Appendix C
NHS Gloucestershire Clinical Commissioning Group
Governing Body Audit Committee (Incorporating the Auditor Panel)
Terms of Reference
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Introduction
1.1. The Audit Committee (the Committee) is established in accordance with Gloucestershire Clinical Commissioning Group’s Constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the Constitution.
2. Membership
2.1. The Committee shall be appointed by the Clinical Commissioning Group as set out in the Clinical Commissioning Group’s Constitution and may include individuals who are not on the Governing Body.
2.2. The membership of the Audit Committee shall include:-
. the lay member of the Governing Body with a lead role in overseeing key elements of governance . two other lay members . two GP Governing Body members
2.3. The lay member on the Governing Body, with a lead role in overseeing key elements of governance, will chair the Audit Committee.
2.4. In the event of the Chair of the Committee being unable to attend all or part of the meeting, he or she will nominate a replacement from within the membership to deputise for that meeting.
2.5. The Chair of the Governing Body shall not be a member of the Audit Committee.
2.6. Members of the Committee shall cease to be members of the Committee if they are no longer members of the Governing Body.
2.7. The members from the GP member practices of the Governing Body shall not be in the majority.
3. Attendance
3.1. The Committee shall invite the Chief Finance Officer, the respective internal and external auditors and a representative of NHS Protect/Counter Fraud to attend meetings of the Committee.
3.2. Additionally the Committee may invite any individual to attend any or part of its meetings.
3.3. The Committee may invite any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the Committee and shall withdraw upon request.
3.4. Any individual invited to attend the Committee may contribute to the proceedings and provide advice and/or guidance to the Committee as requested.
3.5. Notwithstanding the above provisions, external audit, internal audit and local counter fraud and security management providers will have full and unrestricted rights of access to the committee in respect of their audit functions.
4. Secretary
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4.1. The Committee Secretary shall be the Associate Director of Corporate Governance.
5. Quorum
5.1. The quorum of the Committee shall be three members, two of whom must be lay members.
6. Frequency and notice of meetings
6.1. The Committee shall meet not less than four times each financial year.
6.2. The Chair of the Committee may convene additional meetings as required.
6.3. The external auditor or internal auditor may requisition a meeting of the Committee if it is deemed necessary.
6.4. Written notice of meetings and the agenda shall be provided to Committee members not less than 5 working days before the meeting.
6.5. Notice of Committee meetings and the agenda shall also be provided to the Accountable Officer, Chief Finance Officer and the Clinical Commissioning Group employee responsible for internal audit.
6.6. The Committee shall meet in private with the internal and external auditors not less than annually.
6.7. The Committee shall meet with the Accountable Officer not less than annually to discuss and consider the process for assurance that supports the Governance Statement.
7. Remit and responsibilities of the Committee
7.1. The Committee shall critically review the Clinical Commissioning Group’s financial reporting and internal control principles and ensure an appropriate relationship with both internal and external auditors is maintained.
7.2. The key duties of the Committee are:-
Integrated governance, risk management and internal control
7.3. The Committee shall review the establishment of an effective system of integrated governance, risk management and internal control, across the whole of the Clinical Commissioning Group’s activities that support the achievement of the Clinical Commissioning Group’s objectives.
7.4. 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 Clinical Commissioning Group. . the underlying assurance processes that indicate the degree of achievement of the Clinical Commissioning Group’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.
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. 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.
7.5. In carrying out this work the Committee will 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 governance, risk management and internal control, together with indicators of their effectiveness.
7.6. This will be evidenced through the Committee’s use of an effective assurance structure to guide its work and that of the audit and assurance functions that report to it.
Internal Audit
7.7. 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 audit committee, Accountable Officer and the Clinical Commissioning Group. This will be achieved by:
. Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal. . Review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the assurance framework. . Considering the major findings of internal audit work (and management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources. . Ensuring that the internal audit function is adequately resourced and has appropriate standing within the clinical commissioning group. . An annual review of the effectiveness of internal audit.
External audit
7.8. The Committee shall review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:
. Consideration of the performance of the external auditors, as far as the rules governing the appointment permit. . Discussion and agreement with the external auditors, before the audit commences, on the nature and scope of the audit as set out in the annual plan, and ensuring co- ordination, as appropriate, with other external auditors in the local health economy. . Discussion with the external auditors of their local evaluation of audit risks and assessment of the Clinical Commissioning Group and associated impact on the audit fee. . Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Clinical Commissioning Group and any work undertaken outside the annual audit plan, together with the appropriateness of management responses. . To review advice received from the external auditors regarding regulatory issues.
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Other assurance functions
7.9. The Audit Committee shall review the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the Clinical Commissioning Group.
7.10. These will include, but will not be limited to, any reviews by Department of Health arms- length bodies or regulators/inspectors (for example, the Care Quality Commission and NHS Litigation Authority) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).
Counter fraud
7.11. The Committee shall satisfy itself that the Clinical Commissioning Group 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.
Management
7.12. The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
7.13. The Committee may also request specific reports from individual functions within the Clinical Commissioning Group as they may be appropriate to the overall arrangements.
Financial reporting
7.14. The Audit Committee shall monitor the integrity of the financial statements of the Clinical Commissioning Group and any formal announcements relating to the Clinical Commissioning Group’s financial performance.
7.15. The Committee shall ensure that the systems for financial reporting to the Clinical Commissioning Group, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Clinical Commissioning Group.
7.16. The Audit Committee shall review the annual report and financial statements before submission to the Clinical Commissioning Group, 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.
8. Relationship with the Governing Body
Authority
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8.1. The Committee is authorised by the Governing Body to obtain professional advice, including the appointment of external advisor and/or consultants, related to its functions as it deems fit at the expense of the Clinical Commissioning Group.
8.2. The Committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the Committee to fulfil its terms of reference.
Monitoring and Reporting
8.3. The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body.
8.4. The Chair of the Committee shall report the outcome and any recommendations of the committee to the Governing Body.
8.5. The Committee shall report to the Governing Body annually on its work in support of the Statement of Internal Control, specifically commenting on the fitness for purpose of the Assurance Framework process. The Assurance Framework is presented regularly to the Governing Body.
9. Policy and best practice
9.1. The Committee shall have regard to current good practice, policies and guidance issued by the NHS England, the Clinical Commissioning Group and other relevant bodies.
10. Conduct of the Committee
10.1. The Committee shall conduct its business in accordance with these terms of reference and the Clinical Commissioning Group’s governance arrangements.
11 Auditor Panel
11.1 The Audit Committee will fulfil the role of ‘Auditor Panel’, as defined in the Local Audit and Accountability Act 2014 and in accordance with the Department of Health publication ‘Auditor Panels – Guidance to help Health Bodies meet their Statutory Duties, September 2015’.
11.2 The principal role of the Auditor Panel is to advise the Governing Body on the selection, appointment and removal of the Clinical Commissioning Group’s external auditors. The Auditor panel is also responsible for advising the Governing Body on the purchase of ‘non- audit services’ from the external auditor.
11.3 The Auditor Panel will take the form of a separate section of the Audit Committee meeting and will be minuted separately.
Membership, Attendance, Secretary and Quorum
11.4 The membership, secretary and quoracy will be as per the Audit Committee and outlined in Sections 2, 4 and 5 above.
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11.5 The Chief Finance Officer will be invited to attend the meetings. In addition, the Panel may invite any other individual to attend the meetings, as appropriate.
Frequency and notice of meetings
11.6 The Panel will meet as and when required.
11.7 Written notice of the meetings and agendas will be provided, as part of the normal Audit Committee processes, to Panel members not less than 5 working days before the meeting.
Remit and responsibilities of the Panel
11.8 The key duties of the Panel are to advise the Governing Body on:
1. the selection, appointment and removal of the Clinical Commissioning Group’s external auditors; 2. the maintenance of an independent relationship with the appointed external auditor; and 3. the purchase of ‘non-audit services’ from the external auditor.
Monitoring and reporting
11.9 The minutes of each meeting of the Panel will be formally recorded and retained by the Clinical Commissioning Group and submitted to the Governing Body.
11.10 The Chair of the Panel shall report the outcome and any recommendations of the Panel to the Governing Body.
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Appendix D
NHS Gloucestershire Clinical Commissioning Group
Governing Body Remuneration Committee
Terms of Reference
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1. Introduction
1.1 The remuneration committee (the committee) is established in accordance with NHS Gloucestershire Clinical Commissioning Group’s constitution, standing orders and scheme of delegation. 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 clinical commissioning group’s constitution and standing orders.
2. Membership
2.1 The committee shall be appointed by the clinical commissioning group from amongst its governing body members. The members shall include:-
. All Lay members of the Governing Body . CCG Chair . 2 GP members of the Governing Body
2.2 The non-clinical Vice Chair shall be the Chair of the committee.
2.3 No one other than the members of the committee is entitled to be present at committee meetings. The Accountable Officer will only attend when the remuneration and terms of service of other Directors is being discussed
2.4 The committee may invite any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the committee and shall withdraw upon request.
3. Secretary
3.1 The committee secretary shall be the Associate Director Corporate Governance
4. Quorum
4.1 The quorum of the committee shall be three members.
5. Frequency and notice of meetings
5.1 The committee shall meet not less than twice a year.
5.2 Written notice of the date, venue and agenda shall be circulated to all committee members not less than 5 working days before the proposed date.
5.3 The Chair of the committee may convene additional meetings as required.
5.4 The minutes of committee meetings shall be circulated as soon as is practicable after the meeting to which they relate to members of the committee and the Accountable Officer.
6. Remit and responsibilities of the committee
6.1 The committee shall make recommendations to the governing body on determinations about pay and remuneration for employees of the clinical commissioning group and people who provide services to the clinical commissioning group and allowances under any pension scheme it might establish as an alternative to the NHS pension scheme.
6.2 Specifically the committee shall undertake the following:-
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6.2.1 determine the policy regarding terms of service and remuneration of the members of the Governing Body having regard to the provisions of national arrangements where appropriate;
6.2.2 have delegated authority to review the performance and determine the individual remuneration arrangements including any performance related pay for members of the Governing Body;
6.2.3 consult with the Accountable Officer and Chair of the Governing Body in relation to their proposals relating to the remuneration of members of the Senior Management Team;
6.2.4 approve any changes to the standard contract of employment for members of the Governing Body, where applicable, including termination arrangements taking into account relevant guidance and current good practice;
6.2.5 agree terms for the termination of a contract having regard to HM Treasury guidance and current good practice;
6.2.6 approve the terms and conditions, remuneration and travelling and other allowances for members of the Governing Body, including pensions and gratuities;
6.2.7 approve terms and conditions of employment for all employees of the CCG,including, pensions, remuneration, fees and travelling or other allowances payable to employees and to other persons providing services to the CCG;
6.2.8 approve any other terms and conditions of service for the CCG’s employees;
6.2.9 determine the terms and conditions of employment for all employees of the CCG;
6.2.10 determine pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the CCG;
6.2.11 recommend pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the CCG;
6.2.12 approve disciplinary arrangements for employees, including the Accountable Officer (where they are an employee and/or member of the CCG) and for other persons working on behalf of the CCG;
6.2.13 review disciplinary arrangements where the Accountable Officer is an employee or member of another CCG; and
6.2.14 approval of the arrangements for discharging the CCG’s statutory duties as an employer.
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7. Relationship with the governing body
Authority
7.1 The committee is authorised by the Governing Body to obtain legal advice, remuneration or other professional advice, including the appointment of external advisor and/or consultants, related to its functions as it deems fit at the expense of the clinical commissioning group.
7.2 The committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the committee to fulfill its terms of reference.
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Monitoring and Reporting
7.3 The minutes of each meeting of the committee shall be formally recorded and retained by the clinical commissioning group. The minutes shall be submitted to the Governing Body.
7.4 The Chair of the committee shall report the outcome and any recommendations of the committee to the Governing Body.
8. Policy and best practice
8.1 The committee shall have regard to current good practice; policies; and guidance issued by the National Commissioning Board, the clinical commissioning group and other relevant bodies.
9. Conduct of the committee
9.1 The committee shall conduct its business in accordance with these terms of reference and the clinical commissioning group’s governance arrangements.
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Appendix E
NHS Gloucestershire Clinical Commissioning Group
Integrated Governance & Quality Committee
Terms of Reference
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1. Aims
1.1 The aim of the Integrated Governance and Quality Committee is to continuously improve the delivery of healthcare services to the people of Gloucestershire, so ensuring that the services are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements. We will do this by ensuring that controls are in place and are operating efficiently and effectively to deliver the principal objectives of the Governing Body and to set in place processes to manage identified risks, minimising the Clinical Commissioning Group’s exposure to corporate, financial and clinical risks. The Committee will have a pro-active approach to the management of risk and quality, ensuring the organisation learns and takes appropriate corrective action.
2. Core Membership
2.1 The Committee shall be appointed by the Clinical Commissioning Group from amongst its Governing Body members. The members shall include:-
. 3 Lay Members
. Clinical Chair of the CCG, or Deputy
. Accountable Officer
. Chief Financial Officer
. Director of Public Health
. Registered Nurse
. Executive Nurse & Quality Lead
. Director of Commissioning Implementation
. 4 3 GP Governing Body Members
2.2 The Registered Nurse shall be the Chair and one of the GP Members the Vice-Chair of the Committee.
2.3 The Committee may require any person to attend meetings to provide advice and/or expertise as required. Any such person shall not be a member of the Committee and shall withdraw upon request.
3. Secretary
3.1 The Committee secretary shall be the Associate Director of Corporate Governance.
4. Quorum
4.1 Four members of the Committee must be present including at least one clinician member, two lay members and an executive member for the quorum to be established.
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5. Frequency and notice of meetings
5.1 The Committee shall meet bi-monthly.
5.2 Written notice of the date, venue and agenda shall be circulated to all Committee members not less than 5 working days before the proposed date.
5.3 The Chair of the Committee may convene additional meetings as required.
5.4 The minutes of Committee meetings shall be circulated by the Chair as soon as is practicable after the meeting to which they relate to all members of the committee.
6. Remit and responsibilities of the Committee
6.1 The Committee is responsible for the overall development of the Integrated Governance Strategy and to ensure that the appropriate governance plans and mechanisms are in place and being monitored across the following areas:-
. Corporate Governance
. Clinical Governance
. Clinical Effectiveness
. Patient Experience
. Clinical Audit
. Risk Management
. Serious Incident reporting
. Infection Control
. Equality & Diversity
. Service Planning
. Performance in respect of commissioned services
. Information Governance
. Child and Adult Safeguarding
. Health and Safety
. Human Resources
. Research Governance
. Information Governance
7. Governance
Through the delegated authority from the Governing Body the Committee will:
7.1 Monitor and facilitate Clinical Commissioning Gloucestershire compliance against external standards, good practice guidance and legislation;
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7.2 Receive assurances that the CCG responds appropriately to reports from external agencies relevant to integrated governance, e.g. Care Quality Commission, Audit Commission, NICE, Monitor, Health and Safety Executive, NHS Litigation Authority, NHS England Area Team;
7.3 Monitor the Risk Register and Board Assurance Framework ensuring that risks are appropriately prioritised and adequately controlled and that all high and extreme risks are communicated to the Governing Body;
7.4 Review the Committee arrangements to ensure that they remain structurally fit for purpose and to make recommendations for amendments to the Governing Body as appropriate;
7.5 Receive reports from the Local Children and Adult Safeguarding Boards including serious case review reports; and
7.6 Review and approve polices on behalf of the Governing Body. This excludes those policies which the Committee considers to be central to the function of the CCG which the Committee will recommend to the Governing Body for approval and financial policies which will be considered by the Audit Committee
8. Quality Governance
The assurance of quality services commissioned by the CCG will be underpinned by the six dimensions of healthcare quality. We will therefore work to ensure services to the people of Gloucestershire are:
Person-centred; Safe; Effective; Efficient; Equitable and Timely.
We will do this by:
8.1 Ensuring appropriate mechanisms are in place to monitor and drive-forward the quality and safety of services commissioned by the CCG, recommending courses of action where concerns have been identified. Using measures for improvement to assure the Committee of progress in developing services to meet the patient / client’s needs.
8.2 Receiving and mandating action on reports on quality in respect of the CCG’s commissioned services (acute, mental health, community, primary care, independent and any willing/qualified provider); the reports will cover provider performance against CQUINs; patient experience (including complaints and compliments we receive as commissioners), patient safety and clinical performance indicators.
8.3 As part of the annual planning cycle, agree the CQUIN schedule and review implementation by providers.
8.4 Ensuring the patient voice is listened to in order to understand the diversity of the patient experience. This will include consideration of complaints and compliments received by the CCG. The Committee with also receive patient stories at their meetings and consider service delivery from a patient’s perspective in undertaking their governance role.
8.5 Receiving, reviewing and scrutinising reports on serious incidents (SIs) occurring in commissioned services and monitor associated action plans. Requesting additional action / information as necessary, gaining assurance that provider organisations have learnt lessons and taken appropriate action.
8.6 Considering national quality reports and results from relevant national audits and ensuring actions are taken where necessary.
8.7 Reviewing performance against quality indicators in the NHS Outcomes Framework and receiving assurances that concerns are appropriately addressed.
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8.8 Receiving assurances that appropriate systems are in place for the development and review of care pathways, clinical policies and the implementation of NICE guidance and quality standards.
8.9 Reviewing non-financial performance indicators; identifying key areas of focus e.g. infection control.
8.10 Receiving internal and external audit reports relating to quality and follow up action plans and the national Clinical Audit programme.
8.11 Ensuring adequate systems are in place for the governance of research in line with the Department of Health’s requirements.
8.12 Monitoring that arrangements are in place within the CCG relating to equality and diversity issues, ensuring compliance with statutory obligations and implementation of equality plans.
8.13 Both the Committee and the PCCC have an interest in the quality of Primary Care: the IGQC has overall responsibility for quality improvement; and the PCCC has responsibility for providing assurance to the Governing Body on the quality of Primary Care. In recognition of these two roles it is important that the chairs of these respective committees work closely together.
8.143 Annually review and critique the provider quality accounts.
9. Relationship with the governing body
Authority
9.1 The Committee is authorised to conduct its activities that provide assurance to the Governing Body in relation to the following:-
There is an appropriate and fit for purpose range of systems, policies and procedures in place to manage all risks; It has fulfilled its responsibility to manage risk by providing evidence of compliance with all risk management processes The Assurance Framework accurately reflects the organisations objectives and that the associated risks are identified together with the measures and controls to manage these principal risks;
9.2 The Committee shall recommend appropriate action(s) should be taken by the Governing Body in allowing the Committee to fulfil its terms of reference.
Monitoring and Reporting
9.3 The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body.
9.4 The Chair of the Committee shall report the outcome and any recommendations of the committee to the next available Governing Body.
10. Policy and best practice
10.1 The Committee shall have regard to current good practice; policies; and guidance issued
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by the National Commissioning Board, the Clinical Commissioning Group and other relevant bodies.
11. Conduct of the Committee
11.1 The Committee shall conduct its business in an open and responsive manner and in accordance with these terms of reference and the Clinical Commissioning Group’s governance arrangements.
12. Sub-Committees
12.1 The following sub-committees will report to the Integrated Governance & Quality committee and will submit the minutes of their meetings to the Committee for review:
Policy Working Group Clinical Quality Review Groups Gloucestershire Children’s Safeguarding Board Gloucestershire Adults’ Safeguarding Board Clinical Effectiveness sub-committee Information Governance Working Group Individual Funding Request (IFR) panel Equality and Health Inequalities Working Group
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Appendix F
NHS Gloucestershire Clinical Commissioning Group
Priorities Committee Terms of Reference
Strategic purpose The CCG has established a prioritisation process comprising a Prioritisation Framework, a Priorities Committee and individual Funding Request panel. The purpose of the Priorities Committee is to advise the local NHS health economy as to the health care interventions and policies that should be given high or low priority. The priorities committee helps the CCG and its Localities choose how to allocate its resources to promote the health of the local community, based on the local health needs assessment.
Purpose The purpose of the Priorities Committee is to guide and underpin the decision making processes of the CCG and it further supports a consistent approach to commissioning by: • Providing a coherent structure for discussion, ensuring all important aspects of each issue are considered. • Promoting fairness and consistency in decision making from meeting to meeting and with regard to different clinical topics, reducing the potential for inequity. • Providing a means of expressing the reasons behind the decisions made. • Reducing risk of judicial review by implementation of robust decision making processes that are based on evidence of clinical and cost effectiveness within an Ethical Framework. • Supporting and integrating with the development of CCG Commissioning Plans.
Key responsibilities as delegated by the Governing Body:
To set the organisational priorities within which commissioning plans are developed. To provide guidance to the clinical programme groups on the priority areas for their work. To agree programme scope and outcomes to deliver organisational priorities and deliver transformational change. To use a transparent prioritisation framework to agree commissioning priorities, plans and projects; this includes decisions regarding investment, service redesign and disinvestment.
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To review the robustness of the prioritisation framework annually or more frequently if necessary. To agree indicative resources to programmes using a programme budgeting approach. To supervise the development of an annual programme plan for each clinical programme group, that outlines the key priorities and makes explicit the links to the CCG overall strategic objectives, using the programme budget to understand the overall cost of the programme and support decision-making. To receive recommendations (programme business case) for investment, disinvestment and service redesign at least annually. To monitor and resolve impacts between programmes and barriers to progress that require strategic input. To understand the aggregate impact of all clinical programmes on key providers and ensure alignment with overall strategic objectives recommending adjustments to individual programme business cases as required. To ensure that localities and locality plans are sufficiently represented within the programme plans both as generators of evidence/ideas but also as stakeholders with whom the programme consults and as implementation leads. To seek assurance from programme leads that they have consulted with other key stakeholders including partner organisations and communities of interest for that programme and to carry out more strategic consultations through CCG representation at key events and meetings. To sign off the programme business cases ensuring they are resourced and deliverable within the overall organisational financial plans. To agree specific outputs from clinical programme groups as required e.g. new care pathways. To receive and review a programme plan to deliver the business case and receive reports that monitor progress against programme outcomes with quarterly programme updates that demonstrate that the programme plan is delivering.
Membership:
Chair – Clinical Commissioning Group - Chair Vice Chair – Deputy Clinical Chair
Members (or their delegated representatives) CCG GP Governing Body Members CCG Lay Governing Body Members CCG Executive Governing Body Members CCG Healthcare Professional Governing Body Members Director of Public Health (GCC) Director of Adult Services (GCC)
Other CCG staff or representative from other organisations will be invited to attend for specific items on the agenda.
Accountability and reporting:
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The CCG Priorities Committee will be accountable to Gloucestershire Clinical Commissioning Group Governing Body. The Committee will have delegated powers to make decisions on behalf of the governing body as described in the CCG Governing Body constitution.
The CCG Priorities Committee will be responsible for prioritisation across the range of programmes and healthcare services.
The Associate Director Clinical Programmes will provide routine updates to the committee on the progress with the work of the clinical programme groups (CPGs).
The CPG clinical leads will provide information and updates on individual programmes on an ad hoc basis as required.
The Associate Director of strategic Planning will provide regular updates to the committee on progress with specific projects and programmes initiated by the CCG.
Quorum Chair or Vice Chair, 3 CCG GPs, a Governing Body Lay Member, Accountable Officer or Deputy; Chief Financial Officer or deputy; Executive Nurse or Deputy.
Frequency of CCG Priorities Committee A minimum of 4 meetings per annum
Sub-groups All Clinical Programme Groups will formally report to the CCG Priorities Committee.
Secretariat to be provided by The Director of Transformation and Service Re-design team
Agenda and papers: The agenda and papers will be circulated electronically one week prior to the meeting. Agenda items and relevant papers should be submitted at least 1 week prior to this date.
Minutes will be circulated in draft within 5 working days of the meeting to allow members to respond.
Review: These terms of reference will be reviewed annually
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Appendix G
NHS Gloucestershire Clinical Commissioning Group
Primary Care Commissioning Committee Terms of Reference
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Introduction
1. NHS England has delegated authority to the Gloucestershire CCG (GCCG) for the commissioning of primary care as set out in Schedule 2 in accordance with section 13Z of the NHS Act. The detail of the powers of delegation is due to be published by NHS England in January 2015.
2. The GCCG acknowledges that, in addition to the statutory duties set out in Chapter A2 of the NHS Act that it already complies with, it must comply with the following as regards primary care: a) duty to have regard to impact on services in certain areas (section13O); and
b) duty as respects variation in provision of health services (section 13P).
3. The GCCG has established the Primary Care Commissioning Committee (Committee) as a committee of the GCCG Governing Body, in accordance with Schedule 1A of the “NHS Act,” to manage primary care.
4. The members of the GCCG acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.
Aim of the Primary Care Commissioning Committee
5. The purpose of the Committee is to manage the delivery those elements of the primary care healthcare services delegated by NHS England to the GCCG working within the context of the overall CCG Plan. The aim will be to deliver to the people of Gloucestershire, on behalf of the GCCG, services that are of high quality, clinically effective and safe, within available resources. This will be delivered through a culture of openness supported by sound governance arrangements.
Membership
6. The Committee shall consist of the following seven voting members, with actual membership included at Schedule 3:
Lay Chair or their designated deputy Two further Lay Members or their designated deputiesy
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Accountable Officer or their designated deputy Chief Finance Officer or their designated deputy Executive Nurse and Quality Lead or their designated deputy Governing Body Registered Nurse GCCG Governing Body GP (non-voting) A GP not currently working in primary care within Gloucestershire (who may be retired)
7. The Chair of the Committee shall be appointed from the existing Governing Body three lay members, but will exclude the Audit Committee Chair for reasons of good governance and probity. This appointment will be made by the Governing Body.
8. The Vice Chair of the Committee shall be one of the other lay members or the Governing Body Registered Nurse.
9. The Committee will invite the following as non-voting attendees: A HealthWatch representative A Health and Wellbeing Board representative NHS England Area Team
10. The Committee may invite any person to attend meetings to provide advice and/or expertise as required.
Secretary
11. The Committee secretary shall be the Associate Director of Corporate Governance.
Quorum
12. Five members of the Committee must be present for the quorum to be established including: at least two individuals being the lay members or the Governing Body Registered Nurse; and the Accountable Officer or the Chief Finance Officer or their designated deputies.
Meetings and Voting
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13. The Committee will operate in accordance with the GCCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 days before the date of the meeting.
14. The Committee shall meet bi-monthly.
15. The Chair of the Committee may convene additional meetings as required.
16. 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.
17. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution
18. 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.
19. The minutes of the Committee meetings shall be circulated by the Chair as soon as is practicable after the meetings to which they relate to all members of the Committee.
20. Meetings of the Committee shall:
a. be held in public; and
b. the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.
Remit and responsibilities of the Committee
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21. 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.
22. 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 Gloucestershire CCG. This includes delegated responsibility for the following working within the context of the CCG Strategy:
a. The award of GMS, PMS and APMS contracts. This includes: the design of PMS and APMS contracts; and monitoring of contracts;
b. Locally defined and designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);
c. Making decision regarding local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);
d. Procurement of new practice provision;
e. Discretionary payment (e.g., returner/retainer schemes);
f. Approving practice mergers;
g. Primary Care Estates Strategy;
h. Premises improvement grants and capital developments;
i. Contractual action such as issuing breach/remedial notices and removing a contract; and
j. Monitoring Primary Care performance through the Primary Care Operational Group;
k. Improving the quality of Primary Care; and
j.l. Reporting details of 22a – ik to the Governing Body.
23. The Committee shall report on and make recommendations to the Governing Body on the following:
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a. Primary medical care strategy for Gloucestershire;
b. Planning primary medical care services in Gloucestershire (including needs assessment);
24. The Committee may delegate some 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. The Committee may not delegate the procurement of services to any individual or sub-committee.
Financial Accountability
25. The Committee’s authority for procuring services is covered in the GCCG’s scheme of delegation and financial instructions.
Relationship with the Governing Body and Sub-Committees
Relationship with the Governing Body
26. The Committee has delegated authority for the commissioning of some primary care services as outlined in para 22a-ki.
27. The Committee shall make recommendations to the Governing Body for the primary care services and functions listed at para 23a-b.
28. The minutes of each meeting of the Committee shall be formally recorded and retained by the Clinical Commissioning Group. The minutes shall be submitted to the Governing Body. The Chair of the Committee shall report the outcome and recommendations of the committee to the next available Governing Body meeting.
28.29. Both the Committee and the IGQC have an interest in the quality of Primary Care: the Committee has overall responsibility for quality improvement; and IGQC has responsibility for providing assurance to the Governing Body on the quality of Primary Care. In recognition of these two roles it is important that the chairs of these respective committees work closely together.
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Relationship with Sub-Committees
29.30. The NHS Gloucestershire Primary Care Operational Group (PCOG) shall undertake the operational management, implementation and oversight of the nationally defined primary care contracts and the primary care workstreams. In addition the PCOG will also monitor complaints, performance and quality.
30.31. The Primary Care Operational Group sub-committee shall report to the Committee and submit the minutes of their meetings to the Committee for review.
Policy and best practice
31.32. The Committee shall have regard to current good practice, policies and guidance by the National Commissioning Board, GCCG and other relevant bodies.
Conduct of the Committee
332. The Committee shall conduct its business in an open and responsive manner and in accordance with these terms of reference and the GCCG’s governance arrangements.
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Appendix H
Locality Executive Group
TERMS OF REFERENCE
1. Purpose
To provide leadership for developing and implementing clinical commissioning plans at a locality level through the engagement of all practices and other stakeholders in the locality.
2. Objectives
. Fully engage in the clinical commissioning process.
. Work within the financial resources available each year (as set out through the indicative budget allocation)
. Ensure good communication regarding clinical commissioning between and within practices/localities, including dissemination of new care pathways and sharing of best practice.
. Work with the Gloucestershire Clinical Commissioning Group to ensure achievement of its strategic aims.
. Clearly articulate GCCG aspirations and objectives to constituent practices through locality plans.
. Work with Public Health colleagues to respond to the JSNA in order to improve outcomes and address health inequalities.
. Work with the GCCG to ensure PBC supports and enhances the quality, innovation, productivity and prevention (QIPP) agenda.
. Engage and involve patients and/or carers in GCCG developments and service redesign.
. Promote multi-professional involvement within locality clinical commissioning arrangements/structures.
. Feed into contract development to support the contract negotiations with providers e.g. quality, new care pathways.
. Lead service redesign/development and movement of services from secondary to community and primary care settings.
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3. Membership
Nominated Executive GPs from constituent practices Practice manager AHP / other clinical representative Patient representative
Commissioning Director/Executive team lead Medicines Management Finance and Information Public Health Other as required
4. Structure and Frequency of Meetings
The group will be chaired by a locality GP (as agreed by the GP members of the group).
The Chair will ensure that all communications relating to formal meetings are disseminated and papers / reports are circulated in a timely manner.
Agenda items should be forwarded to the Chair a minimum of one week prior to the meeting.
Formal meetings of the Executive will take place on a monthly basis.
5. Responsibility and Accountability
GP Executive members are responsible for ensuring that constituent practices are engaged in agreement and delivery of PBC plans.
GP Executive members are responsible for ensuring communication with the GP members on the Clinical Commissioning Group Governing Body.
Members will be responsible for ensuring that their own organisation or group is fully briefed on all key issues and decisions.
6. Governance and reporting
Governance arrangements are as set out in the PBC Agreement. The Executive Group is responsible for delivering the requirements of the agreement at locality level.
Reporting is to the Clinical Commissioning Group Governing Body and onwards to NHSG Board. The Locality will report to the Clinical Commissioning Group Shadow Board quarterly.
Papers and minutes are to be shared with all constituent GPs and practice managers, and the Clinical Commissioning Group Governing Body and be available to the public on request.
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7. Review of Terms of Reference
These Terms of Reference will be reviewed annually.
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Agenda Item 15
Governing Body
Governing Body Meeting Thursday 24th November 2016 Date Title Standards of Business Conduct Policy
Executive Summary NHS England has recently issued a document entitled ‘Managing Conflicts of Interest: Revised Statutory Guidance for CCGs’. This document outlines a framework that CCGs are expected to follow to ensure that conflicts and perceived conflicts are appropriately identified and managed.
The CCG’s Standards of Business Conduct Policy has been reviewed and revised in order that it complies with the NHSE guidance.
Key Issues The principal revisions to the policy reflect the NHSE guidance in relation to:
the establishment of a Conflicts of Interest Guardian; maintenance of declarations of interest for wider groups of individuals; management of the decision making process when an individual is conflicted; and the management of gifts and hospitality.
All changes made to the existing policy are shown on the attached revision by way of ‘tracked changes’.
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Risk Issues: The absence of a fit for purpose Standards of Business Conduct Policy could result in the probity of commissioning decisions being undermined.
Original Risk (2x4) = 10 Residual Risk (1x4) = 4 Financial Impact None
Legal Issues (including Not Applicable. NHS Constitution) Impact on Equality and Not Applicable. Diversity Impact on Health There are no direct health and equality Inequalities implications contained within this document.
Impact on Sustainable There are no direct sustainability implications Development contained within this document.
Patient and Public Not applicable. Involvement Recommendation The Governing Body is requested to approve the revised Standards of Business Conduct Policy.
Author and Designation Zoe Barnes, Corporate Governance Support Officer Alan Potter, Associate Director of Corporate Governance Sponsoring Director Mary Hutton (if not author) Accountable Officer
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Agenda Item 15
Governing Body
Thursday 24th November 2016
Standards of Business Conduct Policy
1. Introduction
1.1 The existing Standards of Business Conduct Policy was approved by the Integrated Governance and Quality Committee on the 22nd October 2015.
1.2 NHS England commissioned an audit review of the practices for managing conflicts of interest within CCGs in 2015. The final report relating to this review was issued in January 2016 and made a number of recommendations regarding these processes.
1.3 In response to the audit review, and following consultation, NHS England issued the document: ‘Managing Conflicts of Interest: Revised Statutory Guidance for CCGs’.
1.4 The revisions contained within the attached draft policy reflect both the comments made by the auditors and the new NHS England Statutory Guidance.
1.5 The draft policy has been reviewed by a working group comprising the following officers:
Clinical Chair; Lay Member (Governance); Lay Member (PPE); Head of Procurement; Associate Director Corporate Services; and Corporate Governance Support Officer.
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1.6 In addition, comments on the document have been sought from the Joint Staff Consultative Committee and the Integrated Governance and Quality Committee.
2. Changes proposed
2.1 The changes to the existing policy are shown on the attachment by way of tracked changes as follows:
red text – to address the comments made in the audit report; green text – to reflect the NHSE Statutory Guidance; and purple text – refinements made following discussions within the CCG.
2.2 The principal proposed changes made are in relation to:
the roles and responsibilities of senior managers and groups; gifts and hospitality; secondary employment; procurement; registers of interest; and management of breaches.
3. Recommendation
The Governing Body is requested to approve the revised Standards of Business Conduct Policy.
4. Appendix
Standards of Business Conduct Policy
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POLICY AUTHORISATION FORM
1 NAME OF POLICY: Standards of Business Conduct Policy
JOB TITLE OF AUTHOR: Corporate Governance Support Officer
SPONSOR: Accountable Officer
NAME OF GROUP: (if applicable)
2 EQUALITY AND DIVERSITY – Mandatory Requirement An Equality & Diversity assessment has been completed Date Completed: (Please contact the Equality & Diversity Lead)
CONSULTATION NAME OF GROUP (S) (complete where relevant) DATE CONSIDERED Name of Local Committee or Specialist Group? 4th November 2016
JSCC and IGQC Name of Countywide Committee or Specialist Group? County Wide Policy YES / NO Other relevant Forum/Individual? IGQC – circulated electronically
3 APPROVED BY GOVERNING BODY / IGQC NAME i.e. Governing Body DATE APPROVED
Governing Body 24 November 2016 TO BE REVIEWED BY: (Author) DATE TO BE REVIEWED: Corporate Governance team November 2018
4 TO BE COMPLETED BY CO-ORDINATOR DATE PUT ONTO POLICY REGISTER: 2015
POLICY NUMBER: 2
DATE PLACED ON INTRANET:
POLICY UPDATES/CHANGES (AFTER GOVERNING BODY/IGQC APPROVAL) Date Summary of Changes Author/Editor Approved by Version Oct 15 Developed from Conflicts CG Officer IGQC 2 of Interest Policy Oct 16 Updated to incorporate CG Officer GB 5 2016 NHSE Guidance
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The Policy Authorisation Form is part of the overall policy template and forms the front of the document and must be completed in all cases
Equality and Diversity - Part 2 of the form (Appendix 1)
The policy should be checked to see if it has any adverse effect on any personal group covered by Discrimination Legislation. In order to do this an ‘Impact Assessment’ must be completed. Further advice can be obtained from the Equality and Diversity Lead.
Approval & Review - Part 3 of the form
Once the Policy has been approved the name of the group / individual and date of approval should be included. The policy document should be sent to the Policy Co-ordinator to log on the Policy Register.
Review and amendments are the responsibility of the Author and Director of the Policy and a date for review must be set and included on the form. However, the Policy Co-ordinator will give a reminder to an author when a policy is overdue a review. The review date must be at least annually.
If, after a review, changes are made the document must be resubmitted, by the Author, for approval and therefore the ‘Policy for Policies’ must be followed again. Any changes should be included in the necessary ‘Policy updates/changes’ section at the beginning of the document.
CCG Policy Spreadsheet ‘ Information Register’- Part 5 of the form
The Policy Co-ordinator will input the approved policy onto the Policy Register and allocate a Policy Number which will be inserted onto the authorisation form and also communicated to the Author via email. The Policy Co-ordinator will also ensure that after a review a new version number is allocated and noted on the register.
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Standards of Business
Conduct Policy
Version 5.10 (supersedes Conflicts of Interests Policy January 2015) Policy no 2 Author Corporate Governance Support Officer Sponsor Accountable Officer Approved by Governing Body Approval date 22nd October 2015 24th November 2016
Review date 31st October 2016 November 2018
This document may be made available to the public and persons outside of the CCG as part of the CCG’s compliance with the Freedom of Information Act 2000.
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Contents
Section Section Heading Page Number 1 Introduction 6
2 Guidance and Legal Framework 6
3 Responsibilities 8
4 Declarations of Interest 9 9 4.1 Definition 4.2 Conflicts of Interest Guardian 9
4.3 Types 10
4.4 Managing Declarations at Meetings 11
5 Gifts, Hospitality and other areas of Business Conduct 13
5.2 Gifts 13
5.3 Hospitality 14
5.4 Commercial Sponsorship 14
5.5 Secondary Employment 15
5.6 Co-operation with product suppliers 15
5.7 Personal Conduct 16
5.8 Political Activities 16
5.9 Appointing Governing Body or Committee Members 16
5.10 The Commissioning Cycle 17
6 Registers of Interests 18
7 Counter Fraud 19
8 Internal Audit 19
9 Target Audience 19
10 Communication 20
11 Training 20
12 Managing Breaches 20
13 References/ Further Reading 20
14 Commitment to Review 21
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Supporting Documents
Appendix 1 Types of Conflicts of Interests 22
Appendix 2 Declaration of Interest form 24 25 Appendix 3 Declaration of Gifts and Hospitality Form
Appendix 4 Register of Interests – Template 26 Appendix 5 Register of Gifts and Hospitality – Template 28
Appendix 6 Template Declaration of Interest Checklist (for meetings) 29 Appendix 7 Template for Meeting reports 31
Appendix 8 Template Register of Interests declared during a meeting 32 Appendix 9 Procurement Checklist – For commissioning General Practice 33
Appendix 10 Template Procurement Decisions and Contracts awarded 35 Appendix 11 Template Declaration of conflict of interest for bidders/contractors 36
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1. Introduction
1.1. Gloucestershire Clinical Commissioning Group (the CCG) aspires to the highest standards of business conduct and has therefore developed this policy to ensure that the CCG’s Governing Body, all staff, member practices and others acting on behalf of the CCG observe and comply with all relevant legislation and regulations and undertake business in a way that is ethical, and act with integrity at all times.
1.2. The Code of Conduct and Code of Accountability in the NHS (2004) sets out the following three public service values which must underpin the work of the health service. These rules form a basis for this policy and are as follows:
Accountability – everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct.
Probity – there should be an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of NHS duties.
Openness - there should be sufficient transparency about NHS activities to promote confidence between the NHS organisation and its staff, patients and the public.
1.3. Standards of Business Conduct are the standards set and expected of staff who work within the public service sector in order to ensure that they operate with integrity, openness and honesty and are accountable to the public for the actions that they take on behalf of the CCG. The CCG has a duty to ensure fairness and honesty in its relationships with suppliers, contractors, service providers and service users or any other person or organisation with whom it has or might have business connections. This policy sets out how the CCG will manage standards of business conduct and underpins the CCG’s constitution.
1.4. The principles contained within this policy are aimed at GCCG Governing Body Members and are equally applicable to all staff, member practices and others acting on behalf of the CCG who must therefore be aware of this policy and comply with the details within it.
1.5. The policy describes processes and procedures in place to manage standards of business conduct within the CCG in the following areas: in the operation of the CCGs Governing Body; in the procurement of services; commercial sponsorship; the acceptance of gifts and hospitality; further areas of business conduct including private practice and secondary employment.
2. Guidance and Legal Framework
2.1 This policy has considered a number of statutory and regulatory guidance in its development, all of which the CCG expects its staff and employees working on its behalf to comply with. In particular, this policy respects the seven key principles of the NHS Constitution:
The NHS provides a comprehensive service, available to all Page 6 of 37
Access to NHS services is based on clinical need, not an individual’s ability to pay
The NHS aspires to the highest standards of excellence and professionalism
The patient will be at the heart of everything the NHS does
The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.
The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
The NHS is accountable to the public, communities and patients that it serves.
2.2 The Standards of Business Conduct policy also respects the seven principles of public life promulgated by the Nolan Committee, which form a basis for the standards expected of all staff. The seven principles are: Selflessness Integrity Objectivity Accountability Openness Honesty Leadership
The Nolan Principles can be found in full here.
2.3 Bribery Act 2010
The CCG has a responsibility to ensure that all staff are made aware of their duties and responsibilities with regards to the Bribery Act 2010. Under this act there are four offences, the first three are most applicable to the NHS:
Offer, promise or give a bribe to another person to perform a relevant function or activity improperly (this is known as ‘active bribery’).
Request, accept or agree to receive a bribe to perform a function or activity improperly (even if the bribe is not for the recipient’s benefit or is received via a third party). This is known as ‘passive bribery’.
Failure of an organisation to prevent bribery.
Offer, promise or give a financial or other advantage to a foreign public official.
For further information, please refer to the CCG Counter Fraud and Corruption Policy.
2.4 Section 25 of the Health and Social Care Act 2012 imposes duties on CCGs in relation to maintaining registers of interest and managing conflicts of interest. Further guidance was also published in December 2014 to reflect the opportunity for CCGs to take an increased responsibility for commissioning of Primary Care.
2.5 NHS England has also issued guidance for CCGs on the management of conflicts of interest in 2016, and this policy has been updated to incorporate these requirements.
2.6 Staff may also wish to read the Good Governance Standards of Public Services, and
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the Equality Act 2010 in which this policy also respects.
3. Responsibilities
3.1 Gloucestershire CCG
3.1.1 The CCG is responsible for ensuring that the requirements of this policy are brought to the attention of the CCG’s Governing Body, all staff, member practices and others acting on behalf of the CCG and that processes are put in place for ensuring that statutory and regulatory guidelines are effectively implemented.
3.2 Gloucestershire CCG Governing Body
3.2.1 All members of the Governing Body are collectively responsible for decisions made by the organisation and are equally obliged to avoid, and/or manage, any real or perceived material conflicts of interest in accordance with this policy as appropriate.
3.2.2 The Governing Body of Gloucestershire CCG has ultimate responsibility for all actions carried out by staff and committees throughout the CCG’s activities. This responsibility includes the stewardship of significant public resources and the commissioning of healthcare to the community.
3.2.3 It is therefore the duty of the Governing Body to ensure the organisation inspires confidence and trust amongst its patients, staff, partners, funders and suppliers by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decision-making of the CCG.
3.3 Accountable Officer
3.3.1 The Accountable Officer has been given overall responsibility for business conduct and is the Executive Lead on the Governing Body for all corporate governance processes operated by the CCG.
3.4 Chairs of Committees, Sub-committees and Meetings
3.4.1 All Chairs will ensure that meetings are conducted in accordance with this policy and that every meeting gives members an opportunity to declare any conflict of interest in relation to items on the agenda. The Chair is also responsible for ensuring that any declarations are recorded appropriately and suitable action is taken within the meeting, with the assistance of the secretariat for the meeting.
3.4.2 The Chairs have ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action in order to manage this.
3.4.3 In the event that the Chair themselves hold a conflict of interest, the Vice Chair is then responsible for deciding the appropriate course of action. If the Vice Chair is also conflicted then the remaining non-conflicted voting members of the meeting should agree between themselves how to manage the conflict(s).
3.4.4 The Chair of the Primary Care Commissioning Committee (Lay Member) has a particularly important role in the management of conflicts of interest due to the responsibilities the Committee has towards delegated commissioning and the matters that subsequently arise.
3.4.5 It is good practice for the Chair, with support of the CCG’s Associate Director of Corporate Governance, to proactively consider any potential conflicts that may arise at a meeting and consider how these should be managed.
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3.4.6 The Corporate Governance team will be responsible for maintaining the CCG Committee declarations of interest register and ensuring that it is kept up to date with conflicts of interests arising at committees and other meetings.
3.4.7 Further information regarding the management of conflicts of interests at meetings can be found at 6.3.
3.5 Members, Senior Managers and all Staff
3.5.1 All Members including GP Practices, senior managers, staff and others working for or on behalf of the CCG must familiarise themselves with this policy upon their appointment within the organisation. This will include all those acting on behalf of the CCG including contracted and temporary staff and lay persons.
3.6 Associate Director of Corporate Governance
3.6.1 The Associate Director of Corporate Governance will provide advice and assistance to all CCG staff members on matters pertaining to business conduct, and ensure that appropriate registers are maintained (section 6).
3.6.2 The Governance team should be contacted to report any declarations of interests as soon as possible, which will then be recorded as appropriate.
3.7 Audit Committee
3.7.1 The Audit Committee is responsible for reviewing the registers of Conflicts of Interest, Gifts, Hospitality and Commercial Sponsorship including Pharmaceutical rebates on behalf of the CCG Governing Body and receives reports on these at least quarterly.
3.8 Primary Care Commissioning Committee
3.8.1 The Primary Care Commissioning Committee (PCCC) has delegated responsibility for agreeing matters pertaining to primary care, and will therefore ensure it complies with the guidance of this policy in terms of managing conflicts of interest. Further information about how the PCCC will manage conflicts can be found at point 4.3.12.
4. Declarations of Interest
4.1 Definition of a Conflict of Interest
4.1.1 A conflict of interest occurs where an individual’s ability to exercise judgement or act in one role is, or could be impaired or otherwise influenced by his or her involvement in another role or relationship.
4.1.2 Conflicts of interest are not possible to avoid in all instances, however, recognising where and how they arise and dealing with them appropriately will enable the CCG to demonstrate proper governance and decision making with regard to the use of public resources.
4.1.3 The individual does not need to exploit his or her position or obtain an actual benefit, financial or otherwise. A potential for competing interests and/or a perception of impaired judgement or undue influence can also be a conflict of interest.
4.2 Conflicts of Interests Guardian (COIG)
4.2.1 The CCG is required by NHS England to have a Conflicts of Interest Guardian (revised Managing Conflicts of Interests guidance 2016) who will:
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Act as a conduit for members of the public who have any concerns in regard to conflicts of interest; Be the safe point of contact for a whistleblower within the organisation for issues pertaining to conflicts of interest; and Support the rigorous application of conflict of interest principles and policies; Provide independent advice and judgement 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.
4.2.2 Whilst the COIG has an important role within the management of conflicts of interests, executive members of the CCG’s governing body have an on-going responsibility for ensuring the robust management of conflicts of interest, and all CCG employees, governing body and committee members and member practices will continue to have individual responsibility in playing their part on an ongoing and daily basis.
4.2.3 The COIG for the CCG is the Lay Member for Governance and Audit Committee Chair, who will be supported by the Associate Director of Corporate Governance.
4.3 Types of Conflicts of Interests
4.3.1 Types of conflicts of interest that can arise include the following and are fully defined within Appendix 1: Financial interests; Non-financial professional interests; Non-financial personal interests; Indirect interests
4.3.2 It is not possible, or desirable, to define all instances in which an interest may be a real or perceived conflict. It is for each individual to exercise their judgment in deciding whether to register any interests that may be construed as a conflict. Individuals can seek guidance from the Associate Director of Corporate Governance, but as a general rule “if in doubt, declare”.
4.3.3 Accordingly, CCG Governing Body members are required to declare any relevant and material interests, and any gifts or hospitality offered and received in connection with their role in the CCG. Interests that may impact on the work of the Governing Body and should be declared include: any directorships of companies likely to be engaged with the business of the clinical commissioning group; previous or current employment or consultancy positions; voluntary or remunerated positions, such as trusteeship, local authority positions, other public positions; membership of professional bodies or mutual support organisations; investments in unlisted companies, partnerships and other forms of business, major shareholdings and beneficial interests; gifts or hospitality offered to you by external bodies and whether this was declined or accepted in the last twelve months; any other conflicts that are not covered by the above.
4.3.4 A declaration of interests form listing the types of interest that should be declared is attached at Appendix 2. The declaration of interests form must be completed in the following instances:
On Appointment
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4.3.5 Applicants for any appointment to the CCG Governing Body or its Committees are required to declare any relevant interests. If any potential conflicts of interests arise these will be considered on a case by case basis by the recruiting manager and interview panel.
4.3.6 If it is considered that any individual has a material interest in an organisation which provides/is likely to provide substantial business to the CCG they shall not be entitled to be a member of the Governing Body. A material interest can be defined as being so significant that the individual would be unable to make a full and proper contribution to the Governing Body as this interest would preclude them from having involvement in the majority of discussions and decisions.
Every six months
4.3.7 Declarations of interests are routinely collated on a six month basis, with confirmation from all CCG staff that their declared interest(s) are up to date (this includes a nil return where there are no changes). The CCG will adhere to this requirement by use of internal communication channels to remind staff, and within the staff induction programme.
Change of role or responsibility or circumstance
4.3.8 Whenever an individual’s role, responsibility or circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside the CCG or enters into a new business or relationship), a further declaration should be made to reflect the change in circumstances as soon as possible, and in any event within 28 days. This could involve a conflict of interest ceasing to exist or a new one materialising.
4.3.9 Whenever interests are declared they should be promptly reported to the Corporate Governance Support Officer within the Governance team who has designated responsibility for maintaining the register of interests (further information at section 6).
4.4 Managing Conflicts of Interest at Meetings
4.4.1 All members of the Governing Body, sub-committees and meetings will be required to declare any interests in any agenda item before it is discussed or as soon as it becomes apparent, albeit if an interest is declared in the register of interests. Declarations of interest will be recorded in minutes of meetings accordingly, as per NHS England Managing Conflicts of Interest (2016) guidance.
4.4.2 When an interest is declared at a Committee or other decision making body, the Chair should make the decision as to whether that individual remains out of the discussion with regards to the topic in which the interest is declared, or other action taken as appropriate. Further information regarding the Chair’s role can be found at 4.3 of this policy.
Exclusion of Individuals on Account of an Interest
4.4.3 All Governing Body members are required to declare their interests in relation to any items on the agenda at the start of each meeting. Where the conflict is material to the discussion of the Governing Body, that member shall withdraw from discussions pertaining to that agenda item, the conflict and the action will be recorded in the minutes of the meeting and the register of interests updated accordingly.
4.4.4 It is the responsibility of the Associate Director of Corporate Governance to monitor quorum and advise the Chair accordingly to ensure it is maintained throughout the discussion and decision of the agenda item. Should the withdrawal of the conflicted Page 11 of 37
individual result in the loss of quorum, the item cannot be decided upon at that meeting.
4.4.5 Where permitted under the CCG’s Constitution or the conditions of its establishment, the Governing Body has the power to waive restrictions on any clinical professional member participating in the business of the Governing Body, where to authorise such a conflict would be in the interests of the CCG. The application of a waiver can, therefore, be used in the following situations: a member of the Governing Body is a clinical professional providing healthcare services to the CCG that do not exceed the average for other practices and NHS entities commissioned to provide services by the clinical commissioning group; or where the Governing Body member has a pecuniary interest arising out of the delivery of some professional service on behalf of the CCG, and the conflict has been adjudged by the Chair and the Conflict of Interest Guardian not to bestow any greater pecuniary benefit to other professionals in a similar relationship with the CCG.
4.4.6 Where the Chair and the Governance Lay Member have approved the use of the waiver, the Chair must have discussed it with the Accountable Officer before the meeting. In such circumstances where the waiver is used, the Governing Body member: must disclose their interest as soon as practicable at the start of the meeting; may participate in the discussion of the matter under consideration; but must not vote on the subject under discussion.
4.4.7 The minutes of the meeting will formally record that the waiver has been used, and that this policy and the appropriate document provisions have been observed in managing that authorised conflict. Where a member has withdrawn from the meeting for a particular item, the Associate Director of Corporate Governance will ensure that the minutes for that member do not contain such information that may compound the potential conflict, but do not unnecessarily disadvantage the member in their performance of their functions and legal responsibilities.
Decisions Taken With an Interest
4.4.8 In the event of the Governing Body having to decide upon a question in which a member has an interest, all decisions will be made by vote, with a simple majority required. A quorum must be present for the discussion and decision; interested parties will not be counted when deciding whether the meeting meets quorum. Interested board members must not vote on matters affecting their own interests, even where the use of the waiver has been approved by the chairman and used.
4.4.9 All decisions under a conflict of interest will be recorded by the Associate Director of Corporate Governance and reported in the minutes of the meeting. The report will record: the nature and extent of the conflict; an outline of the discussion; the actions taken to manage the conflict; use of the waiver and reasons for its implementation (if applicable).
4.4.10 Where a Governing Body member benefits from the decision, this will be reported in the annual report and accounts, as a matter of best practice. All payments or benefits in kind to Governing Body members will be reported in the CCG’s accounts and
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annual report, with amounts for each Governing Body member listed for the year in question.
4.4.11 As stated within the Constitution, a register of all procurement decisions will be maintained and will also be made publicly available.
4.4.12 Primary Care Commissioning Committee (PCCC) a) Gloucestershire CCG holds delegated commissioning responsibility for Primary Care and therefore has an established Primary Care Commissioning Committee (PCCC). These meetings are generally held in public (with the exception of the closed session) and due to their nature in deciding on Primary Care services, hold a number of potential conflicts of interests risks. b) In the interest of minimising these risks, the CCG ensures that GPs do not have voting rights on the committee. The arrangements do not preclude GP participation in strategic discussions of primary care issues, subject to appropriate management of conflicts of interest. They apply to decision-making on procurement issues and the deliberations leading up to the decision. c) It is also important that conflicts of interests are managed appropriately within sub- committees and sub-groups. Therefore as an additional safeguard, sub-groups must submit their minutes to the PCCC, detailing any conflicts and how they have been managed. The PCCC should be satisfied that conflicts of interest have been managed appropriately in its sub-committees and other relevant groups, and take action where there are concerns.
5. Gifts, Hospitality and other areas of Business Conduct
5.1 Employees of the CCG may accept gifts, sponsorship and/or hospitality under certain circumstances, which are outlined in the following sections of this policy. In the interests of transparency, any offers outside these circumstances must be refused however must still be recorded. A central register will be maintained by the Corporate Governance team and reported to the CCG Core Team and Audit Committee at regular intervals as part of the CCG’s internal assurance process.
5.2 Gifts
5.2.1 A 'gift' is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value.
5.2.2 All gifts of any nature offered to CCG staff, governing body and committee members and individuals within GP member practices by suppliers or contractors linked (currently or prospectively) to the CCG’s business should be declined, whatever their value. The person to whom the gifts were offered should also declare the offer to the Corporate Governance team who have designated responsibility for maintaining the register of gifts and hospitality so the offer which has been declined can be recorded on the register.
5.2.3 Gifts offered from other sources should also be declined if accepting them might give rise to perceptions of bias or favouritism, and a common sense approach should be adopted as to whether or not this is the case. The only exceptions to the presumption to decline gifts relates to items of little financial value (i.e., less than £10) such as diaries, calendars, stationery and other gifts acquired from meetings, events or conferences, and items such as flowers and small tokens of appreciation from members of the public to staff for work well done. Gifts of this nature do not need to be declared for maintaining the register of gifts and hospitality, nor recorded on the register. Page 13 of 37
5.2.4 Any personal gift of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCG) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality and recorded on the register.
5.2.5 Employees must declare any gifts using the form at Appendix 2 whether or not the offer has been refused or accepted to ensure that the employee and the CCG is protected against any subsequent accusation of compromise.
5.3 Hospitality
5.3.1 Hospitality can be described as the friendly reception of guests and visitors for example, a complimentary lunch or dinner whilst attending a conference or training event (of approximately under £25).
5.3.2 A blanket ban on accepting or providing hospitality is neither practical nor desirable from a business point of view however, all offers of hospitality should be approached with caution by employees of the CCG. Any offers of modest hospitality including a drink or a sandwich during an external meeting or free parking to attend a meeting do not require approval from a manager.
5.3.3 Employees should refuse any hospitality which may compromise or be reasonably seen to compromise their ability to exercise judgement in their role. Offers of hospitality including holiday accommodation, sporting fixtures, theatre or other events must be declined.
5.3.4 Hospitality must be secondary to the purpose of the meeting and should not be out of proportion to the occasion or exceed the level which the staff member would normally adopt under normal circumstances when paying for themselves, or that would normally be acceptable to the NHS.
5.4 Commercial Sponsorship
5.4.1 For the purpose of this policy commercial sponsorship is defined as “NHS funding from an external source, including funding of all or part of the cost of a member of staff, NHS research, staff training, pharmaceuticals, equipment, meeting rooms, costs associated with meetings, meals, gifts, hospitality, hotel and transport costs, provision of free services and buildings or premises.”
5.4.2 Commercial sponsorship can include different forms, the most applicable to the CCG include:
Financial support and hospitality for meetings; Attendance at conferences; Publications; Training.
5.4.3 CCG employees should read the ‘Policy for the Joint Working between NHS Gloucestershire CCG and the Pharmaceutical Industry’ in conjunction with this policy where commercial sponsorship is from pharmaceutical companies.
5.4.4 In all cases, CCG employees must declare sponsorship or any commercial relationship linked to the supply of goods or services where this is above the estimated value of £25.00. This should be declared on the form at Appendix 2 of this policy, returned to
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the Corporate Governance team and recorded within the Commercial Sponsorship Register.
5.4.5 As a general rule, sponsorship arrangements involving the CCG will be at a corporate, rather than individual level.
5.4.6 If publications are sponsored by a commercial organisation, that organisation should have no influence over the content of the publication. The company logo can be displayed on the publication, but no advertising or promotional information should be displayed. The publication should contain a disclaimer which states that sponsorship of the publication does not imply that the CCG endorses any of the company’s products or services.
5.4.7 All CCG employees and individuals acting on behalf of the CCG should discuss the implications, with their manager, before accepting an invitation to speak at a meeting organised by a pharmaceutical company. The company should have no influence over the content of any presentation made by the CCG employee/representative. It should be made clear that CCG presence does not imply that the CCG endorses any of the company’s products or services.
5.4.8 Under no circumstances will the CCG agree to ‘linked deals’ whereby sponsorship is linked to the future purchase of particular products or to supply from particular sources.
5.5 Secondary Employment
5.5.1 As per the standard contract of employment, individuals working for the CCG are required to notify the CCG of any secondary employment. This is also covered in the CCG Working Time Regulations Policy. The CCG reserves the right to take action where it believes a conflict will arise which cannot be effectively managed.
5.5.2 The purpose of this is to ensure that the CCG is fully aware of any potential conflicts of interest. Examples of work which might conflict with the business of the CCG include:
Employment with another NHS body; Employment with another organisation which might be in a position to supply goods or services to the CCG; Self employment, including private practice, in a capacity which might conflict with the work of the CCG or which might be in a position to supply goods or services to the CCG; Directorship of a GP federation.
5.5.3 Outside employment and private practice (secondary employment) must be declared as a potential conflict of interest, whether the individual believes it to be a conflict or not.
5.5.4 Should a staff member hold any secondary employment which may conflict with the work of the CCG, the CCG will consider whether, practically, such an interest is manageable at all. If it is not, the appropriate course of action may be to refuse to allow circumstances which give rise to the conflict to persist. This may require an individual to step down from a particular role and/or move to another role within the CCG.
5.6 Co-operation with product suppliers
5.6.1 All requests for co-operation from product suppliers that are received by members of staff should be referred to their senior managers. Suppliers should also be provided with a copy of this policy and the Counter Fraud and Corruption Policy. They must be Page 15 of 37
reminded that the CCG has a zero tolerance approach to fraud and bribery.
5.6.2 There are occasions when it may be beneficial to patients and clients for staff to participate in trials of products and appliances which may be used in the delivery of our services. Patients may ultimately benefit from the development of new products, and being involved in such trials ensures our staff are up to date with current product development.
5.6.3 Any financial incentives offered to staff to participate in such trials should be dealt with in the same way as monetary gifts given by patients. Staff are reminded that if they are asked to participate in any research or trials, this must be submitted to their Line Manager / Director before any agreement to participation is given.
5.6.4 Employees who attend educational meetings or conferences where some part of their costs (registration fees, travel or accommodation) are paid by commercial companies, they must declare the sponsorship to the Corporate Governance team on the form at (Appendix 3) in addition to seeking the usual agreement for study leave.
5.7 Personal Conduct
5.7.1 The lending or borrowing of money between staff should be avoided, whether informally or as a business, particularly where the amounts are significant.
5.7.2 It is a particularly serious breach of discipline for any member of staff to use their position to place pressure on someone in a lower pay band, a business contact, or a member of the public to loan them money.
5.7.3 No member of staff may bet or gamble when at work or on CCG premises, with the exception of small lottery syndicates or sweepstakes related to national events such as the World Cup or the Grand National among immediate colleagues.
5.7.4 Staff who become bankrupt or insolvent must inform their line management and Human Resources as soon as possible. Staff who become bankrupt or insolvent cannot be employed in posts that involve duties which might permit the misappropriation of public funds or involve the handling of money.
5.7.5 A member of staff who is arrested and refused bail or convicted of any criminal offence must inform their line management and Human Resources who will take appropriate action in line with the CCG disciplinary policy. All CCG staff should make themselves aware of the CCG Counter Fraud and Corruption Policy. CCG managers must ensure they adhere to the NHS Management Code of Conduct at all times.
5.8 Political Activities
5.8.1 Any political activity should not identify an individual as an employee of the CCG. Conferences or functions run by a party political organisation should not be attended in an official capacity, except with prior written permission from the Accountable Officer and Chair of the CCG in exceptional circumstances.
5.9 Appointing Governing Body or Committee Members
5.9.1 The CCG needs to consider whether conflicts of interest should exclude individuals from being appointed to the Governing Body or to a Committee or Sub-Committee membership. This will be considered on a case by case basis with reference to the disqualification criteria outlined in the NHS England documents, CCG Governing Body members: Roles outlines, attributes and skills (April 2012), Managing Conflicts of Interests: Statutory Guidance for CCGs and the CCG’s own Constitution.
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5.9.2 In these instances, the CCG will assess the materiality of the interest, in particular whether the individual could benefit from any decision the CCG might make. This will be particularly relevant for Governing Body, committee and sub-committee appointments, but should also be considered for all employees and especially those operating at a senior level.
5.9.3 The CCG will need to determine the extent of the interest and the nature of the appointee’s proposed role within the CCG. If the interest is related to an area of business significant enough that the individual would be unable to operate effectively and make a full and proper contribution in the proposed role, then that individual should not be appointed to the role.
5.9.4 The responsibility for this decision will sit with the recruiting manager for the particular post (usually the Associate Director of Corporate Governance for Governing Body members) in liaison with the interview or appointment panel as appropriate. For committee membership issues, this will be the responsibility of the Chair with advice and support from the Associate Director of Corporate Governance and the Accountable Officer. Sometimes the Governing Body as a whole may discuss the issue together to reach a decision. However, this decision relies on the applicants declaration of interest as outlined in this policy.
5.10 The Commissioning Cycle a) Conflicts of interest need to be managed appropriately throughout the whole commissioning cycle. At the outset of a commissioning process, the relevant interests of all individuals involved should be identified and clear arrangements put in place to manage any conflicts of interest. This includes consideration as to which stages of the process a conflicted individual should not participate in, and, in some circumstances, whether that individual should be involved in the process at all. b) The way in which services are designed can either increase or decrease the extent of perceived or actual conflicts of interest. Particular attention should be given to public and patient involvement in service development.
5.10.1 Commissioning Services from GP Practices
The CCG will abide by the NHS Commissioning Board Code of Conduct ‘Managing conflicts of interest where GP practices are potential providers of CCG-commissioned services’, first published in October 2012 which sets out additional safeguards to use when commissioning services for which GP practices could be potential providers.
5.10.2 Procuring Services a) The management of conflicts of interest is vitally important in the procurement of clinical services and managing them appropriately is paramount to the probity and accountability of the CCG’s decision making and will ensure that the principles of transparency and fairness are upheld. The CCG must and will comply with two different regimes of procurement law and regulation when commissioning healthcare services:
The NHS procurement regime The European procurement regime b) The nature of the CCG means that it is led by GPs, therefore there is an increased risk that conflicts of interest could arise when procuring clinical services. An obvious area in which conflicts could arise is where the CCG commissions (or continues to commission by contract extention) healthcare services, including GP services, in which a member of the CCG has a financial or other interest.
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c) The Procurement Strategy for the Purchase of Healthcare Services considers conflicts of interest that may exist when commissioning services from providers including GP practices, and should be read in conjunction with this policy where appropriate.
Such a conflict could arise:
In carrying out a competitive tender: where GP practices or other providers in which CCG Members have an interest are amongst those bidding to provide those services;
When procuring clinical services through Any Qualified Provider: where one or more GP practice (or other providers in which CCG members have an interest) are amongst the qualified providers from which patients can choose.
In managing conflicts of interests in procuring services the CCG will:
Comply with its statutory obligations in relation to the management of conflicts of interest;
Have regard to relevant guidance published by NHS England in relation to the discharge of its statutory obligations; and
Comply with its constitution in relation to the management of conflicts of interests;
Maintain and publish a register of completed procurements outlining any conflicts of interests declarations;
Make the register of procurement decisions available within its annual accounts.
Regulation 6 of the NHS (Procurement, Patient Choice and Competition) Regulations 2013 requires CCGs to:
Manage conflicts and potential conflicts of interest when awarding a contract by prohibiting the award of the contract where the integrity of the award has been or appears to have been affected by a conflict; and
Keep appropriate records of how conflicts of interest have been managed in individual cases. d) The CCG will complete the Procurement checklist (Appendix 9) when procuring services from providers, to ensure full due consideration is given to the process of procurement. This information will then be transferred onto the Register of procurements decisions and contracts awarded (Appendix 10 and 11) and made publically available. e) Bidders and contractors will be required to declare any potential conflicts of interest that could arise if they were to take part in any procurement process and/or provide services under, or otherwise enter into any contract with, the CCG, or with NHS England. The CCG will request bidders and contractors to complete the form at Appendix 12 of this policy.
6. Registers of Interests
6.1 The CCG is required by NHS England to maintain one or more registers of interest of the members of the group, members of the Governing Body, members of its committees or sub-committees of its Governing Body, and its employees in relation to the issues detailed in section 4 and 5 of this policy: Page 18 of 37
Interests declared at decision making bodies; Interests declared by Governing Body members and other staff which could potentially influence their decision making; Gifts and Hospitality declarations; Commercial Sponsorship
CCGs must publish, and make arrangements to ensure that members of the public have access to these registers upon request.
6.2 Interests will be recorded on the CCG’s Register of Interests as and when they are declared. They should be reported to the Associate Director of Corporate Governance on the relevant form who will maintain the register on behalf of the Accountable Officer. The register will be accessible by the public and inspection of the register of Governing Body members’ interests will be encouraged, as appropriate.
6.3 The CCG will maintain a register of interests for each provider of primary medical services which is a member of the CCG under Section 140 (1) of the 2006 Act. Declarations should be made by the following groups:
GP partners (or where the practice is a company, each director) Any individual directly involved with the business or decision-making of the CCG.
6.4 Any interests must be promptly transferred onto the relevant register and should remain on the public register for a minimum of 6 months after the interest has expired. The register will also remain on file for 6 years after archiving.
6.5 In exceptional circumstances, where the public disclosure of information could give rise to a real risk of harm or is prohibed by law, an individual’s name and/or other information may be redacted from the publicly available register(s). Where an individual believes that substantial damage or distress may be caused, to him/herself or somebody else by the publication of information about them, they are entitled to request that the information is not published. Such requests must be made in writing. Decisions not to publish information must be made by the COIG for the CCG, who should seek appropriate legal advice where required, and the CCG should retain a confidential un-redacted version of the regsiter(s).
6.6 The register(s) of interests (including the register of gifts and hospitality) will be published as part of the CCG’s Annual Report and Annual Governance Statement.
7. Counter Fraud
7.1 The CCG aims to ensure that all staff can feel supported should they have any concerns of dishonest or fraudulent behaviour conducted at their workplace.
7.2 Staff concerned about how to raise their suspicions can receive independent and confidential advice from their Local Counter Fraud Specialist, the NHS Fraud and Corruption Reporting Line, the online fraud reporting tool (FCROL) - https://www.reportnhsfraud.nhs.uk/; from the charity "Public Concern at Work" or from the CCG’s own whistleblower contact, Alan Elkin (Lay Member).
7.3 Further information about the CCG’s approach to Counter Fraud can be found within the Counter Fraud and Corruption Policy.
8 Internal Audit
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8.1 The CCG will undertake an audit of conflicts of interest management as part of their internal audit on an annual basis and the results of this will be reflected in the CCG’s Annual Governance Statement.
9 Target Audience
9.1 The target audience for the policy is the CCG Governing Body, members of staff, Member Practices and any other persons working on behalf of the CCG or members of CCG committees.
9.2 A copy of this policy will be made available on the CCG external internet site for the public to access, in line with best practice guidance.
10 Communication
10.1 The policy will be sent to members of the Governing Body and the wider CCG membership via email and placed on the CCG intranet site for onward access.
11 Training
11.1 NHS England requires that all CCGs have a structured conflicts of interests training programme in place for all staff. The CCG will use the NHS England mandatory online training package and other training materials in order to comply with this requirement and all staff will be required to complete training on an annual basis in line with NHSE guidance.
11.2 CCG Lay Members and Governing Body members will receive training in accordance with national guidelines, including annual face to face training from NHS England. Training will also be offered to non-CCG members who sit on CCG committees so that they may discharge their duties effectively.
12 Managing Breaches
12.1 Failure to comply with this policy could have serious implications for the CCG and the individuals concerned.
12.2 It is a duty of every CCG employee, Governing Body member, committee or sub- committee member and GP practice member to speak up about genuine concerns in relation to the administration of the CCG’s policy on conflicts of interest management, and to report these concerns. These individuals should speak to the Associate Director of Corporate Governance and/or COIG should they have any concerns.
12.3 Anyone who wishes to report a suspected or known breach of this policy who is not an employee or worker of the CCG, should ensure they comply with their own organisation’s whistleblowing policy.
12.4 All such notification should be treated with appropriate confidentiality at all times in accordance with the CCG’s policies and applicable laws, and the person making such disclosures should expect an appropriate explanations of any decisions taken as a result of any investigation.
12.5 Individuals who fail to disclose any conflict of interest or who otherwise breach the CCG’s rules and policies relating to the management of conflicts of interest are subject to investigation and, where appropriate, to disciplinary action. CCG staff, Governing Body and committee members should be aware that outcomes of such action may, if appropriate, result in the termination of their employment or position with the CCG.
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12.6 Any deliberate failure to declare an interest will be addressed through the relevant CCG disciplinary route with the individual concerned.
13 References/Further reading
13.1 Please find listed below details of organisations used in researching this protocol. NHS Commissioning Board – Towards establishment: Creating responsive and accountable clinical commissioning groups (February 2012)
NHS Commissioning Board – Towards establishment: Technical Appendix 1 - Managing conflicts of interest (February 2012)
NHS Commissioning Board – Code of Conduct: Managing conflicts of interest where GP practices are potential providers of CCG commissioned services (June 2012)
ICSA Guidance Note 120228 – Model conflicts of interest policy for clinical commissioning group board members (February 2012)
NHS Confederation / RCGP Centre for Commissioning – Managing conflicts of interest in clinical commissioning groups (September 2011)
NHS England – Managing Conflicts of Interest: Statutory Guidance for CCGs April 2016 (V2)
NHS Protect – Bribery Act 2010 Guidance 2015
Department of Health - Commercial Sponsorship – Ethical Standards for the NHS
NHS England - CCG Governing Body members: Roles outlines, attributes and skills (April 2012)
CCG Improvement and Assessment Framework (March 2016)
The Good Governance Standards for Public Services (2004)
The Equality Act (2010)
Standards for members of NHS Boards and CCG governing bodies in England
14 Commitment to Review
14.1 The CCG will review this policy at least every three years and where required in order to comply with new guidance and regulations as appropriate.
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Appendix 1 Types of Conflicts Interests can be captured in four different categories:
Financial Interest
This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:
A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possible seeking to do, business with health or social care organisations. 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 possible seeking to do, business with health or social care organisations. A management consultant for a provider.
Non-financial professional interests
This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:
An advocate for a particular group of patients; A GP with special interest e.g. in dermatology, acupuncture etc A member of a particular specialist professional body (although routine GP membership of the 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 the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE) A medical researcher.
GPs and practice managers, who are members of the governing body or committes of the CCG, should declare details of their roles and responsibilities held within their GP practices.
Non Financial Personal Interest
This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:
A voluntary sector champion for a provider; A volunteer for a provider; A member of a voluntary sector board or has any other position of authority 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.
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, a:
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Spouse/partner Close relative e.g. parent, grandparent, child, grandchild or sibling; Close friend; Business partner.
A declaration of interest for a ‘business partner’ in a GP partnership should include all relevant collective interest of the partnership, and all interests of their fellow GP partners (which could be done by cross referring to the separate declarations made by those GP partners, rather than by repeating the same information verbatim).
Whether an interst held by another person gives rise to a conflict of interests will depend upon the nature of the relationship between that person and the individual, and the role of the individual within the CCG.
Further information on examples of situations that may arise can be found within the NHS England case studies which can be found here.
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Appendix 2
Declaration of Interest form
Name: Position within, or relationship with, the CCG (or NHS England in the event of joint committees): Detail of interests held (complete all that are applicable): Type of Description of Interest (including for Date interest Actions to be Interest* indirect Interests, details of the relates taken to mitigate risk *See relationship with the person who has the From & To reverse interest) (to be agreed of form with line for manager or a details senior CCG manager)
The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds.
I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result.
I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons:
Signed: Date:
Signed: Position: Date: (Line Manager or Senior CCG Manager)
Please return to the Corporate Governance Support Officer, Sanger House
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Appendix 3
Declaration of Gifts and Hospitality Form
Name: Position: Date of offer:
Details of Gift/Hospitality: Date of Receipt (if applicable):
Estimated Value:
Supplier/Offeror Name and Nature of Business:
Details of previous offers or acceptance Declined or Accepted? : by this offeror/supplier:
Reason for Accepting/Declining:
Details of Officer reviewing the offer:
Other Comments / Supporting Information:
The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds.
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I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result.
I do / do not (delete as applicable) give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons:
Signed: Date:
Signed (Line Manager): Position: Date:
Please return completed form to the Corporate Governance Team, Sanger House within 28 days of the interest arising.
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Appendix 4 Register of Interests – Template
Name Current Relevant Business Interests Interest Type Direct or Date of Last Action taken to mitigate Position Indirect Submission Updated (where changed)
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Appendix 5
Template Register of Gifts and Hospitality
Name Position Date of Declined or Date of Description Value Supplier/Offeror Nature of Reason for Offer Accepted? Receipt (est) Business accepting/declining
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Appendix 6 Template Declarations of Interest checklist (For meetings) Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings. This checklist has been developed with the intention of providing support in conflicts of interest management to the Chair of the meeting – prior to, during and following the meeting. It does not cover the requirements for declaring interests outside of the committee process.
Timing Checklist for Chairs Responsibility
In advance of 1. The agenda to include standing Chair and secretariat the meeting item on declaration of interests to enable individuals to raise any issues and/or make a declaration at the meeting.
2. A definition of conflicts of Chair and secretariat interest should also be accompanied with each agenda to provide clarity for all recipients.
3. Agenda to be circulated to Chair and secretariat enable attendees (including visitors) to identify any interests relating specifically to the agenda items being considered. Meeting members 4. Members should contact the Chair as soon as an actual or potential conflict is identified. Chair 5. Chair to review a summary report from preceding meetings i.e. sub-committee, working group, etc, detailing any conflicts of interest declared and how this was managed. Chair
6. A copy of the members’ declared interests is checked to establish any actual or potential conflicts of interest that may occur during the meeting.
During the 7. Check and declare the meeting Chair meeting is quorate and ensure that this is noted in the minutes of the meeting
8. Chair requests members to Chair declare any interest in agenda Page 29 of 37
items – which have not already been declared, including the nature of the conflict
9. Chair makes a decision as to Chair and Secretariat how to manage each interest which has been declared, including whether/to what extent the individual member should continue to participate in the meeting, on a case by case basis, and this decision is recorded.
10. As minimum requirement, the Secretariat following should be recorded in the minutes of the meeting: Individual declaring the interest; At what point the interest was declared; The nature of the interest; The Chair’s decision and resulting action taken; The point during the meeting at which any individuals retired from and returned to the meeting – even if an interest has not been declared
Following the 11. All new interests declared at Individual(s) declaring meeting the meeting should be promptly interest(s) updated onto the declaration of interest form. Designated person 12. All new completed declaration responsible for registers of of interest should be transferred interest into the register of interests.
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Appendix 7
Template for Meeting reports Committee Name
Meeting Date
Report Title
Executive Summary
Key Issues
Risk Issues: Original Risk Residual Risk
Management of Conflicts Include details of conflicts of interest to be declared. of Interest Confirm recording of interest on the register of interests.
Financial Impact
Legal Issues (inc luding Think about NHS Constitution issues here as well. NHS Constitution)
Impact on Health Not acceptable to say Yes or No. This must be described in Inequalities more detail and an Equality Impact Assessment completed.
Impact on Equality and Yes/No – an assessment should be completed Diversity If yes describe Impact on Sustainable Development
Patient and Public Involvement
Recommendation Paper for information only or decision
Author Designation Sponsoring Director (if not author)
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Appendix 8
Template Register of Interests declared during a meeting The CCG will hold one register per meeting
Date of Meeting Name Title Agenda item Interest Action taken
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Appendix 9 Procurement Checklist – For Commissioning General Practice
Service:
Question Comment/ Evidence
1. How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities? How does it comply with the CCG’s commissioning obligations?
2. How have you involved the public in the decision to commission this service?
3. What range of health professionals have been involved in designing the proposed service?
4. What range of potential providers have been involved in considering the proposals?
5. How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?
6. What are the proposals for monitoring the quality of the service?
7. What systems will there be to monitor and publish data on referral patterns?
8. Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers?
9. In respect of every conflict or potential conflict, you must record how you have managed that conflict or potential conflict. Has the management of all conflicts been recorded with a brief explanation of how they have been managed?
10. Why have you chosen this procurement route e.g., single action tender?1
1Taking into account all relevant regulations (e.g. the NHS (Procurement, patient choice and competition) (No 2) Regulations 2013 and guidance (e.g. that of Monitor). Page 33 of 37
11. What additional external involvement will there be in scrutinising the proposed decisions?
12. How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process and award of any contract?
Additional question when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) or direct award (for services where national tariffs do not apply)
13. How have you determined a fair price for the service?
Additional questions when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) where GP practices are likely to be qualified providers
14. How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?
Additional questions for proposed direct awards to GP providers
15. What steps have been taken to demonstrate that the services to which the contract relates are capable of being provided by only one provider? 16. In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract? 17. What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?
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Appendix 10 Template Procurement decisions and contracts awarded
Procurement Total Title Existing Contract Decision Summary of Conflicts of & Contract GCCG Provider Contract Value Making Contract Procurement Interest Declared and Tender or Commissioni Name & Start & Committee End Date Type how these were Reference / New ng Area Address Date Contract & managed Advertisement Procurement Value to Process Reference GCCG Example:
Provision of Out New Urgent Care SWAST 1 April 31 March £21M OJEU Out of County GP – Governing of Hours P Procurement and 2015 2018 Restricted Clinical Director in a Body Medical Contracting £21M Procedure Social Enterprise who Services might bid for the Full service. The organisation commercial NGPT 42 / 2014 didn’t bid. technical Senior and financial 2014S / 123456 Manager Engagement & evaluation Inclusion – Married to a based on the registered paramedic most employed by one of the economically bidding advantageou organisations. The s tender individual’s line manager monitored the evaluation to ensure it was conducted in a fair and robust manner. Procurement Specialist – Married to a registered paramedic employed by one of the bidding organisations. Not involved in the decision making process.
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Appendix 11
Template Declaration of conflict of interests for bidders/contractors
Name of Organisation:
Details of interests held:
Type of Interest Details
Provision of services or other work for the CCG
or NHS England
Provision of services or other work for any other potential bidder in respect of this project or procurement process
Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
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Name of Relevant [complete for all Relevant Persons] Person
Details of interests held:
Personal interest or that of a family Type of Interest Details member, close friend or other acquaintance?
Provision of services or other work for the CCG
or NHS England
Provision of services or other work for any other
potential bidder in respect of this project or procurement process
Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.
Signed:
On behalf of:
Date:
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APPENDIX E: CCG Equality Impact Analysis – The EIA Form
1 What’s it about? Refer to equality duties What is the proposal? What outcomes/benefits are you hoping to achieve? Standards of Business Conduct outline how staff should apply ethical conduct and integrity to every day working and covers a range of issues including: Declarations of interests Commercial sponsorship Bribery This policy aims to describe the CCG’s process for managing standards of business conduct and provides a clear set of principles for all staff to follow. Who’s it for? Staff, Lay Members, Agency/contracted staff, those acting on behalf of the CCG. How will this proposal meet the equality duties? Ensure all staff members have a process to follow if they are involved in this area. What are the barriers to meeting this potential? Staff being unaware of the policy. This will be addressed by publication on the staff website and reference in the staff newsletter. 2 Who is using it? Refer to equality groups
What data/evidence do you have about who is or could be affected (e.g. equality monitoring, customer feedback, current service use, national/regional/local trends)? Not applicable How can you involve your customers in developing the proposal? Policy will be made available on the CCG website in line with the model publication scheme and transparency responsibilities. Who is missing? Do you need to fill any gaps in your data? (pause EIA if necessary) Perhaps those who do not have access to the internet, in which case a written application for the policy could be made under the Freedom of Information Act 2000.
3 Impact Refer to dimensions of equality and equality groups Show consideration of: age, disability, sex, transgender, marriage/civil partnership, maternity/pregnancy, race, religion/belief, sexual orientation and if appropriate: financial economic status, homelessness, political view, gypsies & travellers, sex workers, people who misuse drugs & alcohol Using the information in parts 1 & 2 does the proposal: a) Create an adverse impact which may affect some groups or individuals. Is it clear what this is? How can this be mitigated or justified? Not applicable What can be done to change this impact? Not applicable b) Create benefit for a particular group. Is it clear what this is? Can you maximise the benefits for other groups? Not applicable Does further consultation need to be done? How will assumptions made in this Analysis be tested? None
4 So what? Link to business planning process What changes have you made in the course of this EIA? None – not applicable What will you do now and what will be included in future planning? Not applicable When will this be reviewed? Not applicable How will success be measured? Not applicable
For the record
Name of person leading this EIA Date completed Zoe Barnes 8th October 2016 Names of people involved in consideration of impact
Name of director signing EIA Date signed Alan Potter 8th October 2016
Agenda Item 16
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Assurance Framework 2016/17
Executive Summary The attached Assurance Framework for 2016/17 provides details of the assurances that will be provided to the Governing Body regarding the achievement of the CCG’s objectives.
The Assurance Framework identifies gaps in assurances and controls regarding the objectives along with details of the principal high-level risks that have been identified by lead managers.
Key Issues A number of risks have been identified which could adversely affect achievement of the objectives. Action plans have, however, been devised and are being implemented to minimise the effect of these risks.
Risk Issues: The absence of a fit for purpose Assurance Framework could result in gaps in control or assurances not being identified and addressed.
Original Risk 8 (2x4) Residual Risk 4 (1x4) Financial Impact Not applicable Legal Issues Not applicable (including NHS Constitution) Impact on Health None Inequalities Impact on Equality None and Diversity
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Impact on Sustainable None Development Patient and Public Not applicable Involvement Recommendation The Governing Body is requested to note this paper and the attached Assurance Framework. Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director Cath Leech (if not author) Chief Finance Officer
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Agenda Item 16
Governing Body
Thursday 24th November 2016
Assurance Framework 2016/17
1. Introduction
1.1 The Assurance Framework provides the Governing Body with a structure and process that enables the organisation to:
focus on those high-level risks that could compromise achievement of the organisational objectives; map out the key controls in place to manage the objectives; and identify the assurances that will be received by the Governing Body regarding the effectiveness of those controls.
1.2 The Assurance Framework is also a key source of evidence for the Annual Governance Statement.
1.3 The principal benefit of the Assurance Framework is that it provides a structure for individuals within the CCG to consider and plan for the achievement of the organisation’s objectives in a proactive manner.
2. The Assurance Framework
2.1 The Assurance Framework is based upon the six summary objectives outlined in the 5 Year Plan for 2014/19.
2.2 The document outlines the principal high-level risks, control systems and assurances provided to the Governing Body regarding the achievement of each summary objective. Details of the action plans to address the risks, gaps in controls or gaps in assurance are also provided.
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2.3 Progress regarding the achievement of each objective is monitored separately through the performance management process.
2.4 This version of the Assurance Framework was considered at the October 2016 meeting of the Integrated Governance and Quality Committee (IGQC). Further updates of the document will be provided to future meetings of both the IGQC and the Governing Body.
3. Recommendation
3.1 The Governing Body is invited to note this paper and the attached Assurance Framework.
4. Appendix
Appendix 1: Assurance Framework
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Gloucestershire Clinical Commissioning Group ‐ Assurance Framework 2016/17 Appendix
Risk Controls Assurances Actions / Status Risk ID Principal Risks to achieving strategic Risk Owner(s) Original Current Key Controls Gaps in Sources of Assurance Gaps in Assurances Actions objectives Risk Risk Controls Ratings Ratings (LxC) (LxC)
Objective 1: Develop strong, high quality, clinically effective and innovative services. L2 Risk to the quality, resilience and sustainability Ian Goodall 12 (3x4) 12 (3x4) Practice visits by Executive Team and Primary Care Ongoing monitoring, appointments made within Senior Management of Primary Care of Primary Care due to GP practices running at Helen Edwards CCG Lead GPs; Senior Locality Commissioning team, Investment to support unplanned admissions DES to practices, new ways of maximum capacity and certain practices not Andrew Hughes Manager attendance at Locality Committee, Primary working pilots, funding identified to support Primary Care initiatives. Localities working being financially viable. Stephen Rudd Executive meetings; Implementation Care Operational together on new ways of working. (March 2017) Jenny Bowker of Countywide Practice Manager Group, Risk and Issues Increasing examples in 2016/17 of practices Representative Group; Exercising log. becoming unsustainable, with this likely to Delegated Commissioning continue through 2016. Responsibilities; close working with member practices. Furthermore ‐ NHS Property Services are notifying practices occupying health centres of significant increases in facility costs in 2016/17.
T13 Risk around the specialised services for children Simon Bilous 12 (3x4) 16 (4x4) Monitoring service provision with Assurance from Area NHS England in process of procuring extra bed capacity nationally. But some cases are and young people with mental health problems Adele Jones local providers and feedback to Area Team still not being found appropriate provision in a timely way which can have an impact on due to specialised commissioning transferring Kathryn Hall Team. Issue raised in CQC review local systems with inappropriate admissions to GRH or Wotton Lawn. to NHS England leading to fragmentation of report. pathways. Opportunities for co‐commissioning with NHS England are being explored.
Local work ongoing includes changing the service arrangements for crisis support and psychiatric liaison including extending the age range to include u18s and u16s respectively as part of overall Children's Mental Health Transformation Plan; and developing additional options for care and support of young people in need of accommodating in a crisis (Safe Places / Place of Safety) ‐ jointly with the council and other partners.
T14 Ensuring there is sufficient project Kelly 12 (3x4) 12 (3x4) Project Resource identified, Performance reports 1. 2016/17 CPG programme agreed. management resource and buy in to deliver the Matthews/Ruth documented and agreed across all to Governing Body transformation programme/QIPP across all Hallett/Kathryn CPGs. Projects to have a CCG 2. Clinical Programmes Board established as part of the STP. organisations. Hall Director as Project Sponsor and a GP Lead along with relevant provider 3. PIDs developed for agreed Prioritisation projects. representation. Agreed 2016/17 QIPP Schedule with providers. 4. Clinical Programme Approach under development to include a focus for a design for delivery exploring integrated working across the system.
Objective 2: Work with patients, carers and the public to inform decision making. Objective 3: Transform services to meet the future needs of the population, through the most effective use of resources; ensuring the reduction of harm, waste and variation.
Page 1 Gloucestershire Clinical Commissioning Group ‐ Assurance Framework 2016/17 Appendix
Risk Controls Assurances Actions / Status Risk ID Principal Risks to achieving strategic Risk Owner(s) Original Current Key Controls Gaps in Sources of Assurance Gaps in Assurances Actions objectives Risk Risk Controls Ratings Ratings (LxC) (LxC)
Q5 Risk to financial performance if prescribing Teresa 8 (2x4) 12 (3x4) The primary care prescribing budget Performance reports Prescribing savings plan is a total of £3.99m. This is made up from £3.5m from primary costs are in excess of the agreed budget. Middleton has been agreed and will be to Governing Body care prescribing and 0.49m from secondary care Drug partnership. There are robust monitored. plans (upwards of 25 individual plans) in place to deliver this savings target, which are monitored through the fortnightly Medicines Optimisation Programme Group regularly reporting to core team meetings.
In addition to the above savings plans have been established for Centralised Continence Supplies (£66k) and Care homes pharmacist medication reviews (£366k).
C3 Increased risk of CCG receiving legal challenge David Porter 12 (3x4) 12 (3x4) Ensure that EU procurement process Project reports to Continual adherence to European Union Public Contracts Regulations 2015 and the as a result of competitive tendering following is followed for all procurement Core Executive Team National Health Service (Procurement, Patient Choice and Competition) (No.2) the introduction of the EU Remedies Act, the exercises (above and below) the EU and Governing Body Regulations 2013 National Health Service (Procurement, Patient threshold in accordance with DoH, Choice and Competition) (No 2) Regulations 1 Cabinet Office and Government April 2013 and the Public Procurement (The Procurement Service Guidelines. Public Contracts Regulations 2015).
C5 (Discharge) Risk that system partners will be Maria Metherall 16 (4x4) 12 (3x4) A&EDB, Urgent Care Programme Performance Reports Continual monitoring and review via the A&EDB 4‐hour Improvement Plan and unable to effectively deliver a timely and Board, Urgent Care Strategy Group and dashboards, consolidated with focus on admission avoidance and system‐wide flow. Monitoring and coordinated approach to patient flow and critical milestones review to be undertaken through the UC Programme Board and A&E Delivery Board discharge ensuring a reduction of patients who reviewed, regular throughout 2016/17. remain in the acute trust when medically stable programme and with a LOS greater than 14 days. stocktake.
C6 (Acute Care) Non‐delivery of the Constitution Maria Metherall 12 (3x4) 12 (3x4) A&EDB, Urgent Care Programme Performance Reports Continual monitoring and review via the A&EDB 4‐hour Improvement Plan and standard for maximum wait of 4 hours within Board, Urgent Care Strategy Group to Governing Body, consolidated with focus on admission avoidance and system‐wide flow. Monitoring and the Emergency Department. weekly situation review to be undertaken through the UC Programme Board and A&E Delivery Board report, project status throughout 2016/17. updates.
C8 (inc (Signposting & Admission Avoidance ) Risk of Maria Metherall 12 (3x4) 12 (3x4) A&EDB, Urgent Care Programme Performance Reports Monitoring via the A&EDB High Impact Four Hour Improvement Plan and Four Hour C28) failure to reduce demand and prevent Board, Urgent Care Strategy Group to Governing Body, Recovery Plan. Remedial action plan in place and agreed with provider. Monitoring and unnecessary acute attendances and emergency weekly situation review through Contract Management Board arrangements. Continuous assurance admissions. report, project status around training and recruitment plan for workforce in place. Work with GCS to increase updates. SPCA focus on admission avoidance and assurance that all GPs are using the service.
T10 (inc Delayed implementation of QIPP Projects Ian Goodall 12 (3x4) 12 (3x4) Robust project management Performance reports All projects to have clear baseline monitoring with agreed KPIs. F12) and/or failure of projects to deliver anticipated planning and reporting to the PMO. to Governing Body. Monthly project monitoring with focus on schemes at risk of non‐delivery, with benefits could result in under‐delivery on agreement on remedial action. planned care QIPP savings target. Planned care QIPP manager recruit to Trust. Transformation projects may not deliver the Monthly QIPP Review meetings for Planned Care and Urgent Care. expected outcomes.
Page 2 Gloucestershire Clinical Commissioning Group ‐ Assurance Framework 2016/17 Appendix
Risk Controls Assurances Actions / Status Risk ID Principal Risks to achieving strategic Risk Owner(s) Original Current Key Controls Gaps in Sources of Assurance Gaps in Assurances Actions objectives Risk Risk Controls Ratings Ratings (LxC) (LxC)
C15 Failure to comply with the NHS Constitution Annemarie 12 (3x4) 12 (3x4) Acute provider contracts, including Performance Reports Number of targets Insufficient planned care capacity to meet demand could result in increasing waiting lists national and local access targets for planned Vicary AQP. to Governing Body not being met, and inability to meet waiting time targets, impacting on the quality of local health care; including 2ww, over 52ww, 62 day cancer insufficient capacity services. The IST will begin working with Urology at GHFT in relation to their capacity and target, diagnostic 6‐week target, planned in planned care. demand modelling. follow‐ups could result in inadequate and/or A number of targets regularly not being met, including 62 day cancer target, 6 week wait delayed care. for diagnostics, and a small number of 52 week wait breaches have been reported. Change fortnightly calls to weekly from October to monitor plans and trajectories. Monthly access and performance meeting arranged to discuss progress. Attendance at Trust internal cancer performance meeting. Recovery action plans in place in a number of areas. Monthly communications being sent to GPs regarding waiting times across providers to encourage informed choice. Waiting times have been included on G‐Care as part of the referral process. Some patient transfers underway for long waiters, although this is primarily in General Surgery and Urology. Increase in Urology community outpatient services. (August 2016)
C34 Impact on discharges due to delays sourcing 12 (3x4) 12 (3x4) GCC CPAC / Brokerage for LA funded Performance Reports Maintain regular monitoring of performance/progress at quality groups. Daily updates independent sector domiciliary care. service users to Governing Body for the System Call. Demand and capacity being mapped to try and understand underlying issues and monitored as part of the implementation of dom care new contracting arrangements. Extension to Hospital Rapid Discharge service supporting the new 'Hospital to Home' to run concurrently. F11 ‐ Failure to deliver financial targets. Cath Leech 12 (3x4) 12 (3x4) Robust financial plan aligned to Budgets approved by Ongoing work to ensure financial commitments are affordable and CCG is achieving a F16 commissioning strategy. the Governing Body. recurrent balance (at least quarterly). The delivery of 2016/17 financial performance Monthly reporting to targets are dependent upon QIPP performance in the last six months of the financial CCG Governing Body. year. Work on Sustainability and Transformation plan within the Health Community is being refined with a final submission due in October leading to two year contracts.
Robust contract management and Monthly performance Monthly performance meeting which reviews all contracts (including out of county) activity monitoring and validation dashboard for larger together with Contract Boards and Finance & Information Groups for larger contracts. (particularly at GHFT) contracts with robust out of county contract monitoring reflected within performance reports.
Financial procedure being refreshed. Internal audit plan in Procedures have been reviewed. place and internal audit reports and recommendations to be reported to Audit Committee. F17 (inc The CCG will be using the lead provider Cath Leech 12 (3x4) 12 (3x4) Regular contract monitoring Governing Body The CCG will access support from NHSE in undertaking the process. If the contract is F19) framework for the procurement of meetings. reports awarded to an alternative provider then a group will be set up to manage the contract commissioning support services. This process transition may mean a different provider is chosen. This could mean disruption to services during the period of procurement and transition.
F18 Lack of alignment of IM & T strategy with Cath Leech 12 (3x4) 12 (3x4) ICT Programme Group Governing Body Each project will be costed and prioritised by the CCG to determine whether to take partner and provider organisations. reports forward.
Page 3 Gloucestershire Clinical Commissioning Group ‐ Assurance Framework 2016/17 Appendix
Risk Controls Assurances Actions / Status Risk ID Principal Risks to achieving strategic Risk Owner(s) Original Current Key Controls Gaps in Sources of Assurance Gaps in Assurances Actions objectives Risk Risk Controls Ratings Ratings (LxC) (LxC)
C35 Risk of break in Primary Care OOH service Gill Bridgland 12 (3x4) 12 (3x4) Procurement Project Board, Core Monthly reports to Options paper to Part II of GCCG Governing Body meeting on 28.07.16. Legal Advice has provision if alternative provider is not Team and Governing Body. Core Team and been sought. Project Board has been set up to oversee the fast track procurement to contracted from 1 June 2017 Governing Body secure a 10 month contract. Advert will be placed for 10 month contract on 3 October 16.
C36 Risk of failure to meet A&E Delivery Priorities Maria Metherall 12 (3x4) 12 (3x4) A&E Delivery Board Performance Reports . Baseline assessment tool completed and presented to September A&E Delivery Board. NEW to support safe and effective services through to Governing Body Director level responsibility agreed with key delivery dates. A number of actions were RISK winter. contained within existing work programmes. Directors are responsible for updates on progress at A&E Delivery Board given the importance of delivery. . Winter plan produced from all system partners including updated system Escalation Framework. Winter Workshops arranged fro operational managers/leads. . Demand & Capacity modelling underway ‐ due to be presented to October A&E Delivery Board. . October A&E Delivery Board to consider current schemes and their effectiveness in order to support winter. . Workforce remains the largest risk to delivery.
Objective 4: Build a sustainable and effective organisation, with robust governance arrangements throughout the organisation and localities. F20 Shared Record Project ‐ It will not be possible Cath Leech 12 (3x4) 12 (3x4) Governing Body Escalation to HSCIC. to get data from SystmOne practices in the reports Meet with TPP (supplier for SystmOne). short‐term. Seek alternative method of sharing TPP data. Regular calls with other shared care record programmes This requires having EDSM (intra‐SystmOne (Birmingham/Surrey/Nottingham/Leeds). sharing) switched on which makes the entire Review options. patient record available to all other SystmOne users (i.e. national) which may put patients off and is a different model to that agreed for JUYI. The only current way to share with the JUYI solution would be via the MIG.
Objective 5: Work together with our partners to develop and deliver ill health prevention and care strategies designed to improved the lives of patients, their families and carers. Q17 Higher than expected mortality in GHT patients Kay Haughton 12 (3x4) 12 (3x4) Ongoing monitoring of data. CCG Governing Body Audit and action plan produced. Item remains on CQRG agenda and is actively experiencing fractured neck of femur. presence on #NOF working group. performance reports discussed. CCG representation from MSK CPG attends GHT #NOF Group and also the Monitoring of GHT Action Plan #NOF Action Plan is monitored via the CCG CQRG
Objective 6: Develop strong leadership as commissioners at all levels of the organisation, including localities.
Page 4
Agenda Item 17
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Integrated Governance and Quality Committee (IGQC) minutes Executive Summary The attached minutes provide a record of the IGQC meeting held on the 18th August 2016. Key Issues The following principal issues were discussed:
Quality Report; Primary Care Quality Report; Children in Care Annual Report; Experience and Engagement Report; Annual Sustainability Report; Risk Register; Assurance Framework; Information Governance; Joint Local Area Special Educational Needs and disabilities; and Review of Data Security. Risk Issues: Not applicable Original Risk Residual Risk Financial Impact Not applicable
Legal Issues (including Not applicable NHS Constitution) Impact on Health None Inequalities Impact on Equality and None Diversity Impact on Sustainable None Development Patient and Public Not applicable Involvement Recommendation The Governing Body is requested to note these minutes which are provided for information.
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Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director Julie Clatworthy (if not author) IGQC Chair and Registered Nurse
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Integrated Governance and Quality Committee (IGQC)
Minutes of the meeting held on Thursday 18th August 2016, Board Room, Sanger House
Present: Julie Clatworthy JC Chair Dr Charles Buckley CBu GP Liaison Lead – Stroud Locality Dr Caroline Bennett CBe GP Liaison Lead – North Cotswold Mary Hutton (part MH Accountable Officer meeting) Marion Andrews-Evans MAE Executive Nurse and Quality Lead Colin Greaves CG Lay Member – Governance Alan Elkin AE Lay Member – Patient and Public Engagement
In Attendance: Teresa Middleton TM Deputy Director of Quality Georgina Smith (Item 9) GS Sustainability Advisor Liz Ponting (Item 12) LP Senior Quality and Development Manager Rob Mauler RM Patient Experience and Safety Manager Alan Potter AP Associate Director of Corporate Governance Fazila Tagari FT Corporate Governance Support Officer
1. Apologies for Absence
1.1 Apologies were received from Mark Walkingshaw, Sarah Scott and Dr Tristan Lench.
2. Declarations of Interest
2.1 All GPs declared a general interest.
3. Minutes of the meeting held on 23rd June 2016
3.1 The minutes of the meeting were accepted as a true and correct record subject to the following amendments:
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Section 5.6 to be amended to read ‘MAE had suggested to NHS England that a national centre was established to deal with all the residual CHC claims.’ Section 6.4 to be amended to read ‘The Committee recorded their congratulations and thanks to Helen for her work on Safeguarding in the CCG’ Section 16.5 to be amended to read ‘CG understood that there had been certain negativity permeating through the 360° survey and was interested to understand if it was the same practices.’
4. Matters Arising
4.1 IGQC144 Experience and Engagement Report MAE advised that the national guidance had been issued relating to primary care engagement and it was noted that there was no impact for the CCG due to the delegating commissioning arrangements. Item Closed.
4.2 IGQC155 Quality Report MAE advised that a summary explaining the definition of falls and how these were reported by providers would be included in the October 2016 Quality Report.
4.3 IGQC170 Quality Report The Stroke and TIA improvement plan update would be presented at the October 2016 meeting.
4.4 IGQC172 Quality Report The update regarding the surgical site infection surveillance was covered within the Quality Report and that further updates would be reported via this mechanism. Item Closed.
4.5 IGQC173 Primary Care Quality Report RM advised that the primary care complaints dashboard had been developed and would be covered under Agenda Item 8 (Experience and Engagement Report). Item Closed. Page 2 of 17
4.6 IGQC 6.7 Quality Report It was noted that further update was awaited regarding MAE the one Never Event that was reported by the Dean, part of Ramsey Health
4.6 IGQC176 Transforming Care Workstream The work of the Transforming Care Programme was highlighted to the Governing Body on the 28th July 2016 as part of the Accountable Officer’s Report. Item Closed.
4.7 IGQC177 Risk Register AP confirmed that Risk No T14 had been reworded to make reference to QIPP and STP. Item Closed.
4.8 IGQC178 Major Incident Plan MAE confirmed that the acronym ‘S/SC’ had been clarified within the final document. Item Closed.
4.9 IGQC179 Information Governance Update The briefing report regarding the opt-out process for the Joining Up Your Information project was emailed to members on the 1st August 2016. Item Closed.
5. Quality Report
5.1 MAE presented the Quality Report which provided assurance to the Committee that quality and patient safety issues were given the appropriate priority and that there were clear actions to address them. The report was taken as read.
5.2 CBu advised that the Clinical Effectiveness Group (CEG) was reviewing published provider performance information from the National Audits which would identify areas where the level of care falls below the regional and national standards. It was noted that a local working group had been established to review this area of work that would meet on a monthly basis to identify and highlight areas of concern.
5.3 MAE advised that she attended the opening of the Page 3 of 17
Fritchie Centre in Charlton Lane by the 2gether Trust and noted that it would provide a dedicated base for dementia research. MAE advised that this would be a countywide resource centre.
5.4 MAE updated members on the annual NHS Emergency Planning Resilience and Response assurance process and advised that Andy Ewens had been meeting with providers to review their annual self- assessment to ensure that these were correct. It was noted that NHS England and NHS Improvement had also been involved in the process. MAE indicated that this was also an agenda item at the NHS England, Quarter 2 Assurance meeting. It was noted that the CCG self-assessment would be presented to the September Governing Body.
5.5 MAE drew attention to Section 7 of the report which updated members on safeguarding reviews. The Committee expressed concerns regarding the protracted review period. It was noted that the named GP for Safeguarding Adults and Children had been useful in assisting GPs with the process.
5.6 Members were informed that Stinchcombe Manor Care Home was subject to a large scale enquiry as a number of concerns had been raised. MAE advised that the GP providing the care home enhanced service was being supported by the CCG. It was noted that the GP had not highlighted any previous concerns. CBe suggested that short guidance was produced for GPs explaining the process for raising any concerns. MAE advised that guidance had been issued when the Care Homes Enhanced Service was initially launched and concurred that a further reminder should be issued to remind GPs of the process.
5.7 AE suggested that a checklist was prepared in order to MAE make GPs aware of any signs to look out for when visiting care homes.
5.8 RM indicated that the CCG were considering procuring a Quality Alerts reporting system. However, this could Page 4 of 17
not be progressed with due to costs. RM advised that the CCG was running a pilot with the Pathology Team at GHFT for reporting incidents and noted that improving care homes reporting was also being explored. Other approaches included linking with the G-Care website. It was noted that discharge delays was the strongest theme arising from the alerts. RM advised that alerts from smaller providers had also been emerging and that the process was being reviewed.
5.9 JC queried the frequency of risk training provided for practices and what support was in place to encourage practices to report incidents. CBu highlighted that one of the pledges from the Sign up to Safety campaign was reporting incidents and questioned if additional publicity should be raised to promote this further. RM highlighted that NHS England had the ultimate responsibility for managing primary care complaints.
5.10 MAE informed members that one Never Event was reported by the Dean, part of Ramsey Health following the death of a patient. It was noted that there had been ongoing concerns which had been raised. It was noted that the service was contracted by GCC and therefore the incident and the concerns were being been managed by them.
5.11 JC highlighted the two suicides that had been reported and queried if these were being followed up. MAE advised that they were discussed at a recent Clinical Quality Review Group (CQRG) meeting. It was highlighted that suicide rates tend to be higher during the spring and summer months. Members noted that a Suicide Prevention Group had been established in the South West.
5.12 JC highlighted the improvement in the level of pressure ulcers reported by GCS and enquired of the rationale underpinning this. MAE advised that this was an area of focus driven forward by the GCS Director of Nursing and highlighted that a Working Group had also been established to review cases. It was noted that a joined Page 5 of 17
up approach with GHFT had also been key.
5.13 MAE informed members that the three areas of focus stated by NHS Improvement were falls, pressure ulcers and infection control.
5.14 JC enquired of the lessons learnt arising from the MAE serious incident involving the Gloucestershire Diabetic Eye Screening programme and was advised that a further update can be provided at the October 2016 meeting.
5.15 MAE drew attention to Section 15 of the report which updated members on the surgical site infection. JC noted the minimal information provided.
5.16 MAE advised that GHFT had recently appointed a new chair for its Quality Committee who had requested to meet with Kay Haughton in order to discuss and identify any areas of improvements.
5.17 MAE reported that all the district nurses vacancies had been backfilled, although concerns had been raised regarding the GHFT vacancy rates. MAE advised that GHFT currently had 114 WTE registered nurses vacancy rates in the Medicines Department. The Committee expressed concerns particularly regarding the reliance on expensive agency workers to make up the shortfall in staff and the associated financial implications. The continuity of care for patients was also a key concern highlighted.
MH joined the meeting at 10.00
5.18 AE highlighted Section 4.2 of the GCS CQRG minutes held on the 14th June 2016 relating to the mortality report and sought assurance that issues were being addressed. MAE advised that Hannah Williams managed the End of Life pathway and that there was a strong focus on this area.
5.19 MAE informed members that the End of Life Strategy MAE/ would be presented to the September Governing Hannah Page 6 of 17
meeting. JC requested that a further update on Williams mortality was presented to the Committee in December 2016.
5.20 Members were informed that the CQC was inspecting MAE GCS that week reviewing mortality rates as a result of the Southern Health review. MAE advised that random trusts had been selected as part of unannounced inspections regime by CQC. It was agreed that a further update was presented at the December IGQC meeting.
5.21 RECOMMENDATION: The Committee noted the contents of this report.
6. Primary Care Quality Report
6.1 MAE presented the Primary Care Quality Report which provided assurance to the Committee that quality and patient safety issues were given the appropriate priority and that there were clear actions to address them. The report was taken as read.
6.2 AE highlighted that 10% of the practices in Gloucestershire had not established a Patient Participation Group (PPG). MAE advised that support had been provided to those remaining practices. It was agreed that Becky Parish and Helen Goodey would liaise with the practices to address this.
6.3 JC questioned the support available for the practices which required improvement following a CQC inspection and enquired if a quality improvement programme was available. MAE advised that this had been discussed at the Primary Care CQRG and noted that there was only one practice that required improvement and that they would be working with the Primary Care Team to review this.
6.4 AE requested that headings were added to each page MAE in the dashboard of the completed and published GP CQC inspection reports.
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6.5 MAE advised that support would be provided to those practices that required improvements in some domains, although rated as generally ‘good’. It was noted that an agreed process had been developed with the Primary Care Team and NHS England. CBu asked if ‘outstanding’ practices could identify best practice which could be shared with other practices who were awaiting inspections.
6.6 RECOMMENDATION: The Committee noted the contents of this report.
7. Children in Care Annual Report
7.1 MAE presented the 2015/16 Annual Health Report for Children in Care which was taken as read. The report contained details of the operational delivery by health organisations within Gloucestershire for children in care.
7.2 JC enquired if follow ups were made for the MAE / Gloucestershire children in care placed outside of Annette Gloucestershire. MAE advised that this should be Blackstock routine practice and agreed that she would confirm this.
7.3 CG drew attention to a typographical error on page 2 of the report and highlighted that it should read as ‘in the year ending 31 March 2016’
7.4 AE queried what strategies were in place to support children who had detachment issues and the rationale for placing Gloucestershire children out of county.
7.5 JC commended the quality of report and felt that the addition of the governance section was helpful.
7.6 RECOMMENDATION: The Committee noted the progress and service delivery of health services for Children in Care in Gloucestershire.
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8. Experience and Engagement Report
8.1 RM presented the Experience and Engagement Report which was taken as read. RM also gave a presentation, which covered:
summary; provider friends and family test; primary care friends and family test; themes of the contacts received; complaints 2015/16; primary care complaints; Mapline; and patient experience examples.
8.2 RM highlighted that the Friends and Family Test (FFT) for GHFT Emergency Department response rate had improved and reported that the June 2016 response rate was 8.3% compared to 0.8% in January 2016 and that the national average was 13.4%. RM advised that GHFT had recently changed providers in relation to the test and were trialling different methodologies.
8.3 RM provided an update on the primary care FFT response rate and advised that the response rate had been categorised by the list size as previously requested by CBu. RM advised that 29 practices had not submitted any data and that 13 practices had not submitted data for the previous three months. It was noted these had been flagged with the Primary Care Team and reminders would be issued highlighting that these were contractual requirements.
8.4 RM advised that fewer contacts had been received compared to the previous year and that 120 contacts had been received in Quarter 1, 2016/17 compared to 187 in the Quarter 1, 2015/16 although it was noted that enquiries had been increasingly complex. RM advised that the complaints regarding Continuing Healthcare (CHC) claims were increasing and felt that a review of the complaints policy was required in order to streamline the process for the CHC Team. Page 9 of 17
8.5 RM advised that the CCG had received the first full year of KO14a data (hospital and community health services complaints collection – excluding primary care). RM advised that the data reported was not directly comparable between trusts and the CCGs as the guidance was ambiguous on what should be counted and excluded i.e. Wiltshire CCG included complaints regarding acute trusts within their figures whereas Gloucestershire CCG did not.
8.6 RM presented the Primary Care complaints dashboard which had been developed by NHS England. The Committee noted the minimal qualitative information the dashboard provided. RM advised that feedback would be relayed to NHS England.
8.7 Members were shown a business intelligence mapping software called ‘Mapline’ which plotted all the contacts received by the Engagement Team on a map in order to identify any hotspot areas. RM presented the Quarter 1 data which highlighted themes in a particular geographical area and noted that the software was still being developed.
8.8 RM updated members regarding the non-emergency patient transport issue which was reported at the previous Committee. Members noted that concerns that had been raised by a member of the public and how the CCG was systematically using feedback from experience activity and engagement to inform the commissioning cycle. It was noted that concerns had been raised regarding the alleged callous response to the complaints provided by GHFT.
8.9 AE drew attention to table 2 of the results of the 2015 CBu National Cancer Patient Experience Survey and highlighted Q15 and Q35 performance relating to ‘patient told about side effects that could affect them in the future’ and ‘patient was unable to discuss worries or fears with staff during visit’ respectively. AE expressed concerns as the results had decreased since 2014. CBu understood that the questionnaire Page 10 of 17
was quite complex and that a narrative had proved to be useful in the past. Results would be fed back to the Cancer CPG. It was noted that further work was being undertaken to support and improve the performance in this area of work. CBe queried if there had been capacity issues and requested that a comprehensive analysis was undertaken to identify any issues. MAE considered that communication was a key theme emerging from the survey and that a further focus on communication was required. JC requested that the action plan in response to the survey was shared with the Committee.
8.10 RECOMMENDATION: The Committee noted the contents of this report and the presentation.
TM left the meeting at 10.50
9. Annual Sustainability Report
9.1 GS presented the 2015/16 Sustainability Report which provided an update on the CCG’s progress on sustainable development. Members noted that the CCGs key providers constituted 86.8% of the carbon footprint for the area. The report was taken as read.
9.2 GS advised that benchmarking of the provider performance also ensured that providers optimise the efficient use of resources.
9.3 GS explained that the carbon contribution of what the CCG procures accounted for a further 12.9% of the carbon footprint which was almost entirely (99%) accounted for by the pharmaceuticals (medicines). GS advised that there were significant programmes of work in place to optimise the use of medicines across Gloucestershire.
9.4 GS advised that GCS had made a commitment to reduce its carbon footprint and to reduce its environmental impact across key areas of the Trust. Key actions including installing renewable energy.
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9.5 Members noted that the overall number of tonnes of waste produced at Sanger House had reduced by 14% in 2015/16 and that the proportion of waste recycled was 64%.
9.6 GS informed members that business mileage undertaken by staff at the CCG had increased in 2015/16 and that this would be reviewed in 2016/17.
9.7 GS advised that the CCG measured its impact as an organisation on a number of areas i.e. estates, procurement, travel and adaptation through the use of the Good Corporate Citizen Benchmarking Tool and noted that the CCG measured comparatively well.
9.8 CBe enquired if the level of medical interventions could be reviewed with providers as part of the sustainability programme. GS advised that this would be covered as part of the Sustainability and Transformation Plan.
9.9 JC queried if there were further practical measures that GS could be implemented at Sanger House. GS advised that NHS Property Services were unresponsive to any discussions. The Committee requested that the issue was formally escalated at a senior level.
9.10 CG queried how Gloucestershire benchmarked with other areas and was advised that the results of the Good Corporate Citizen Benchmarking provided that information.
9.11 RECOMMENDATION: The Committee noted the contents of the sustainability report and that it would be available on the CCG website and CCG Live.
LP joined the meeting at 11.00
10. Risk Register
10.1 AP presented the Risk Register which provided details of those risks identified by the responsible managers that currently face the CCG and which could affect the Page 12 of 17
achievement of the organisational objectives and included additional information regarding the red risks as requested at the previous Committee.
10.2 The Risk Register comprised a total of 36 risks, one of which was graded as ‘red’ as outlined in Appendix 1. In addition, the Committee were asked to consider the addition of the one new risk detailed on Appendix 2 and approve the closure of the five risks detailed on Appendix 3.
10.3 JC requested that Risk No T7 regarding the lack of capacity within Public Health should be further updated. MAE advised that two additional Public Health Consultants had recently been recruited.
10.4 CBu queried if the rating for Risk No Q17 relating to the mortality rates at GHFT should be reassessed. CBu understood that there had been no significant movement made with the action plan. MH advised that there was new leadership in place and suggested that further time was given to the plan to evaluate any improvements. It was agreed that the risk was reviewed at the next meeting.
10.5 RECOMMENDATION: The Committee: reviewed the paper and the attached Risk Register; approved the addition of the new risk (Risk No TC35) detailed on Appendix 2; and approved the deletion of the five risks (Risks Nos C18, F8, Q7, C32 and Q16) detailed on Appendix 3.
11. Assurance Framework
11.1 AP presented the Assurance Framework for 2016/17 which provided details of the assurances that will be received by the Governing Body regarding the achievement of the CCG’s Objectives. The paper was taken as read.
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11.2 AP informed members that only high level risks with a rating above 12 were included within the Assurance Framework in order to provide focused discussions.
11.3 RECOMMENDATION: The Committee noted this paper and the attached Assurance Framework.
12. IFR Policy - Non-generic phosphodiesterase -5 inhibitors
12.1 LP presented the Policy which proposed for the restriction of non-generic sildenafil prescribing for erectile dysfunction. LP advised that the IFR policy recommended that all non-generic sildenafil treatments become ‘interventions not normally funded’ (INNF) where exceptionality was required for funding via the Individual Funding Request (IFR) process.
12.2 LP advised that feedback from the GHFT Urologist had been positive and supportive and that there were no major objections.
12.3 CBu advised that there were other cost effective drugs available on the market which had similar treatment. CBu suggested that GP communications included references to the evidence and additional information detailing alternative treatment options.
12.4 AE understood that there was little evidence to support any proven benefit for the use of Tadalafil for post- surgical use of penile rehabilitation and queried if there were any evidence. LP advised that evidence indicated that the treatment success rate was reliant on how the operation was managed by the surgeon and highlighted that alternative treatments were also available. CBu highlighted that the evidence had not been sufficiently robust.
12.5 JC queried the number of patients who would be affected by the change. CBu advised that this information was not available and recognised that this would be difficult for some patients and that exceptional circumstances would only warrant Page 14 of 17
treatment and articulated that evidence indicated that other drugs had similar success rates.
12.6 JC queried if engagement with Healthwatch had been undertaken. MH advised that this would be addressed through the implementation process. CG requested that the Communications Team were involved in the process.
12.7 RECOMMENDATION: The Committee approved the policy and noted that the date for implementation was to be agreed.
LP left at 11.35
13. Information Governance Update
13.1 CL presented the paper which provided an update on the organisation’s information governance arrangements. The paper was taken as read.
13.2 CL advised that the 2016/17 work programme including evidence for the IG toolkit had been developed and was being implemented. The work programme included a structured training programme for staff particularly those who handle patient identifiable information and Governing Body members which will be held on the 1st December.
13.3 CL advised that NHS Digital (previously HSCIC) were reviewing the CCG 2015/16 information toolkits and were assured with the information.
13.4 CL advised that the review of data security in the NHS by Dame Fiona Caldicott, the National Data Guardian, had been published in July 2016 and that further details were covered as part of Agenda Item 16.
13.5 Members noted that a national review was being undertaken reviewing type 2 patient opt-outs and that CSU would be leading on this work.
13.6 CG was interested in the mandatory training statistics Page 15 of 17
for staff and the Governing Body and requested that this was monitored as he understood that the deadline for completing the training was imminent. CL advised that the deadline was September 2016 and highlighted that the previous year statistics were positive and would be reviewed at the Information Governance Working Group meeting.
13.7 RECOMMENDATION: The Committee: noted the notes from the Information Governance Group meeting and the CSU briefing; and noted the contents of this report.
14. Outcome of the Joint Local Area Special educational needs and disabilities (SEND) Inspection in Gloucestershire
14.1 MAE presented the report and provided a background context. MAE advised that Ofsted and CQC undertook a joint inspection in the county in June 2016 to assess the effectiveness of the implementation of the special educational needs and disability reforms as set out in the Children and Families Act 2014.
14.2 MAE advised that the findings from the inspection were considered to be positive overall with some areas for improvement being highlighted.
14.3 RECOMMENDATION: The Committee noted the report.
15. Review of Data Security – Consent and Opt-Outs
15.1 MAE presented the report which outlined the recommendations from the review of data security, consent and opt-outs report.
15.2 MAE advised that the CCG already had information security as a high priority and complied with many of the recommendations from this report.
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15.3 MAE advised that the recent public engagement exercise regarding the implementation of Joining Up Your Information complied with these requirements, as it explicitly asked for patients to opt-out and provides them with an easy to use system if they do not want their information shared.
15.4 RECOMMENDATION: The Committee noted the report.
16. Any Other Business
16.1 There were no items of any other business.
17. The meeting closed at 11.45pm.
Date and time of next meeting: Thursday 20th October 2016 in the Board Room at 9am.
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Agenda Item 18
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Primary Care Commissioning Committee (PCCC) minutes Executive Summary The attached minutes provide a record of the PCCC meeting held on the 28th July 2016.
Key Issues The following principal issues were discussed:
Primary Care Strategy; Delegated Primary Care Commissioning Financial Report; Learning/Physical Disability Community Enhanced Service; Sevenposts: Bishops Cleeve premises development; Primary Care Quality Report; and General Practice Forward View Investment Plan.
Risk Issues: Not applicable Original Risk Residual Risk Financial Impact Not applicable
Legal Issues (including Not applicable NHS Constitution) Impact on Health None Inequalities Impact on Equality and None Diversity Impact on Sustainable None Development Patient and Public Not applicable Involvement Recommendation The Governing Body is requested to note these minutes which are provided for information.
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Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director Alan Elkin (if not author) PCCC Chair and Lay Member
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Primary Care Commissioning Committee
th Minutes of the Meeting held on Thursday 28 July 2016 in the Board Room, Sanger House, Gloucester GL3 4FE
Present: Alan Elkin AE Chair Marion Andrews-Evans MAE Executive Nurse and Quality Lead Colin Greaves CG Lay Member - Governance Cath Leech CL Chief Finance Officer Dr Andy Seymour AS Clinical Chair Mark Walkingshaw (part MW Deputy Accountable Officer meeting) In attendance: Helen Goodey HG Director of Primary Care and Locality Development Becky Parish BP Associate Director, Engagement and Experience Cllr Dorcas Binns DB Chair of the Health and Wellbeing Board Andrew Hughes AH Locality Implementation Manager Jeanette Giles JG Head of Primary Care Contracting Stephen Rudd SR Head of Locality and Primary Care Development Claire Feehily CF Chair of Healthwatch Gloucestershire Penny Fowler (part PF Health and Social Care Commissioning meeting) Manager Miriam Street (part meeting) MS Senior Commissioning Manager Alan Potter AP Associate Director of Corporate Governance Fazila Tagari FT Corporate Governance Support Officer There were 4 members of the public present.
1 Apologies for Absence
1.1 Apologies were received from Mary Hutton and Julie Clatworthy.
PCC Committee Minutes 26/05/16
2 Declarations of Interest
2.1 AS declared the following interests: general interest as a GP member; agenda item 7 – as a GP provider for Learning/Physical Disability Community Enhanced Service; and agenda item 10 - General Practice Forward View Investment Plan.
2.2 CF, as a Healthwatch representative declared a general interest in relation to any Patient Participation Group discussions .
3 Minutes of the Meeting held on Thursday 26th May 2016
3.1 The minutes were approved subject to the amendments below:
BPi to be amended to read ‘CFC ’ in the list of attendees. Section 5.1.4 to be amended to read ‘BP provided an update on the engagemennt process and members noted thhat an engagement exercise on the draft Primary Care Strategy would commence following the feedback reeceived at the meeting today.’ Section 5.2.5 to be amended to read ‘HG also confirmed that the CCG had been engaging with ST3s (Speciality TrT ainee, 3rd Year) in collaboration with the Deanery.’
4 Matters Arising
4.1 24.09.2015 AI 5.8 – Springbank Procurement Update – HG confirmed that the nurse led paediatric model from Swindon had been received from NHS England. Item Closed.
4.2 28.01.2016 Item 6.12 - Application to close branch surgeries in Hawkesbury Upton and Wickwar from Culverhay Surgery – JG provided an update and advised that no complaints or negative comments had been received and that the closurees had provided an opportunity to release more appointments at the mmain surgery. It was also noted that concerns had not been raised by patients in relation to patient transport. Item Closed.
4.3 26.05.2016 Item 3.2 - Stow Surgery new premises development –
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AH advised that the Value for Money report had not been completed as it had been recommended that the scheme was assessed by the Building Research Establishment Environmental Assessment Methodology (BREEAM) which was a national standard for assessing the sustainability of new construction devvelopments. As a result of the national standard, the construction costs had increased by approximately £60K. AH advised that the Disttrict Valuer had indicated that the scheme represented significant Value for Money and that the final report should be available shortly.
4.4 26.05.2016 Item 5.1.8 - Draft Primary Care Strategy – CF advised that feedback had been discussed with BP. Item Closed.
5 Primary Care Strategy
5.1 HG presented the draft Primary Care Strategy which was taken as read and provided the background context to developing the strategy. The earlier draft Strategy had been previously presented at the May 2016 PCCC meeting.
5.2 HG advised that this had been the first Primary Care Strategy developed for Gloucestershire which was comprehensive and highlighted that a shorteened version would be prroduced for the wider audience.
5.3 SR provided an update oon the changes that had been made to further develop the Strattegy following the May meeting. These included:
an improved patient focused section; the patient section entitled ‘Listening to and learning from patients’ experiences’ was featured earlier in the document; the most recently published national GP Patient Survey results (July 2016) and the Healthwatch Gloucestershire survey results; the vision and the components were more focused on how the Strategy would improve patient experience and / or health outcomes; and a wider engagement process.
5.4 SR advised that as part of the engagement process, three specific
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questions were asked. These were:
Have we got the right vision? Have we got the right plan to deliver the vision? Have we got the expected outcomes right?
5.5 SR informed members of the feedback received to date and advised that the vision had been widely accepted by the stakeholders, i.e. providers, patient groups, parish councils etc.
5.6 SR advised that he had met with CF and had also included her feedback in the latest draft document. This included addressing health inequalities from the 30,000 ‘place based’ model. SR also advised that CF had agreed to provide support with the development of the patient version document.
5.7 DB suggested that statistics and graphs were included within HG Annex 3 (locality level demographics) and felt that a comparison should be undertaken on a like for like basis in order to distinguish between localities.
5.8 CG stated that he was interested in the format of the short guide and was advised that the process would link with the process that was currently underway to produce a short guide for the STP.
5.10 RESOLUTION: The Committee: recommended that the Governing Body approve the Strategy subject to the comments above; and agreed the proposed approach for a ‘public-friendly’ short guide of the Strategy.
6 Delegated Primary Care Commissioning Financial Report
6.1 CL presented the report which outlined the financial position on delegated primary care co-commissioning budgets as at the end of June 2016.
6.2 CL advised that the CCG had reported an underspend against delegated budgets as at the end of June and anticipated that the CCG would be forecasting a breakeven position for 2016/17.
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6.3 RESOLUTION: The Committee noted the report.
PF and MS joined the meeting at 11.24
7 Learning/Physical Disability Community Enhanced Service
7.1 HG presented the report and provided a background context to the service. HG advised that the CCG had developed an enhanced service over two years ago for the care of older people in nursing and residential homes. The report was taken as read.
7.2 HG explained that the enhanced service had been developed comprehensively and that a QIPP requirement of reducing emergency admissions was included as part of the original specification.
7.3 HG advised that the original service specification did not include the service users with Learning Disabilities (LD) or Physical Disabilities (PD) and that the new service would improve the quality of care for LD/PD service users and provide equity for patients.
7.4 CG understood that the Cheltenham Locality had delivered a successful savings programme. PF advised that the CCG had been reviewing the data for emergency admissions which highlighted that there had been significant decreases in emergency admissions although there were variations by locality primarily accounted for by the number of care homes and the number of practices who had signed up to the service.
7.5 CF enquired of the scope of the intentions and if they covered ophthalmology, podiatry, dental, etc. requirements as these were often health associated issues. AS advised that this should be covered as part of core business.
7.6 CF felt that there was a risk that an opportunity might be missed for social integration for patients who may use the primary care services delivered at the GP practice as a social gain. AS advised that there should be a balance between the two and that patients could visit the practice if there were any health concerns as well as the GP visiting the care homes for assurance.
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7.7 DB highlighted the criteria which stated that each resident should be assessed within two weeks of admission and queried if this was satisfactory and was advised that a fully comprehensive assessment would be undertaken. AS advised that any other requests would be addressed as appropriate.
7.8 MAE requested that the service supported screening services as it was well recognised that people with learning disabilities had significantly lower take-up of health checks, such as cancer screening services.
7.9 BP advised that her team visited the care homes to interview staff and service users as part of the evaluation process and noted that this would be extended to the LD/PD service as part of the overall evaluation process.
7.10 RESOLUTION: The Committee (MW joined the meeting for the vote, AS abstained from voting): considered the recommendation from the Primary Care Operational Group meeting of 19th July 2016; and approved the Care Home Enhanced Service for Nursing Homes, Residential Homes and Supported Living for People with Learning Disabilities or Physical Disabilities.
PF and MS left the meeting at 11.33
8 Sevenposts: Bishops Cleeve premises development
8.1 AH presented the report and provided a background context to the development which was on a greenfield site north west of Bishop Cleeve. The report was taken as read.
8.2 AH advised that on completion of the new surgery, the two current surgeries would close (Sevenposts surgery and Greyholmes surgery) and all services would be provided from the new facility.
8.3 Members were informed that NHS England had approved the previous business case in August 2014 with a requirement that the patient transport issues were resolved and following confirmation by the District Valuer of a positive Value for Money judgement.
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8.4 AH advised that the practice and their advisors had been liaising with the District Valuer and the CCG regarding financial elements, particularly around the impact of reduced land costs resulting from the Section 106 arrangements. It was reported that the District Valuer had now reviewed all elements of the financial appraisal and had confirmed Value for Money.
8.5 AH advised that the scheme would be assessed by the BREEAM approach as it exceeded £2m in value. It was noted that an ‘excellent’ rating was being sought. However, this may not be achievable due to factors outside of the CCG’s control i.e. transportation, land use and ecology reasons. AH assured members, that all, reasonable endeavours would be made to achieve the ‘excellent’ rating and if this proved not be possible, that there would be robust evidence to reflect this.
8.6 DB enquired of the planning application process as she acknowledged that a planning application was being submitted in August 2016. DB queried if an outline planning application had been approved and if the scheme would be approved. AH advised that it would be difficult to speculate the outcome of this application and recognised that this was a potential risk associated with the development. AH also highlighted that there was a time limit associated with the Section 106 which stipulated that agreements should be in place by November 2016 and anticipated that the development should receive approval.
8.7 DB asked if there was a contingency plan in place if the scheme was not approved by the Planning Committee and was advised that this scheme was being submitted on behalf of the practices. Their views had not been sought on the way forward if the scheme did not proceed and if that were the case, that further discussions on the business strategy would be required.
8.8 AE queried if the Premises Strategy would be reviewed in particular ensuring that planning approval was in place for developments and was advised that site identification and securing premises was a key risk as part of the Primary Care Infrastructure Plan in terms of securing value for money. AH also advised that he was working closely with the local authorities to ensure that there was a collaborative approach.
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8.9 CG highlighted that the scheme had generated a great deal of public concern and media interest and recommended that Anthony Dallimore was involved in the communication process.
8.10 BP advised that there had been concerns raised by the Prestbury residents and that the CCG had undertaken regular communication with the stakeholders which included providing regular briefings and travel information. It was also noted that CCG managers have agreed to attend Parish Council meetings.
8.11 AE enquired of the concerns that had been raised by residents and was advised that the distance from home was the primary concern for the Prestbury residents. BP informed members that Georgina Smith had undertaken a transport evaluation which highlighted that there were adequate public transport infrastructures in place although it was recognised that this may not be the preferred option for older and frail patients. BP advised that there was a further development in Cheltenham which could provide an alternative option for patients rather than travel to the new premises. The Committee agreed that trying to ensure continuity of care for patients was an important issue.
8.12 HG proposed that a training session was arranged for the HG / Committee to provide further information on premises development AH and to support effective decision making. The Committee agreed that this would be useful.
8.13 AH suggested that a regular progress report was presented to the AH Committee on a quarterly basis to update members on premises.
8.14 RESOLUTION: The Committee approved the scheme in principle and agreed the financial implications outlined with the report subject to the District Valuer’s Value for Money conclusion.
9 Primary Care Quality Report
9.1 MAE presented the Primary Care Quality Report which provided assurance to the Committee that quality and patient safety issues were given the appropriate priority and that there were clear actions to address them. The report was taken as read.
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9.2 MAE advised that the Primary Care Clinical Quality Review Group had been cancelled and that there had been issues with insufficient GP representations at this meeting.
9.3 Members noted that the responsibility for complaints and concerns in relation to primary care still remained with NHS England. It was noted that the NHS England national complaints team were developing an approach which would allow some information to be shared with CCGs.
9.4 MAE advised that the Named GP for Safeguarding Adults and Children had now commenced her role and was already busy in her area of work.
9.5 MAE updated members on the Friends and Family Test (FFT) results for primary care and noted that the response rates were low, which was in line with other areas nationally. MAE advised that work was ongoing to improve response rates.
9.6 It was noted that the CCG had established the Gloucestershire Patient Participation Group (PPG) Network. It was also noted that over 90% of practices had established a PPG.
9.7 MAE updated members on the Care Quality Commission (CQC) inspections of Gloucestershire practices and noted that the dashboard of published CQC inspections reports was summarised in Appendix 1 of the report. MAE understood that there had been two practices that required improvement and assured members that there were no patient safety issues raised.
9.8 Members were informed that the CCG achieved all three improved antibiotic prescribing Quality Premium targets for 2015/16 although it was recognised that there was further work to undertake on antibiotic prescribing. In order to support this work, a Medicines Optimisation Programme Group had been established and the appointment of an Independent GP Prescribing support.
9.9 CF stated that the mechanisms in place to capture feedback from the public in relation to primary care services should be strengthened. MAE concurred and advised that there were other
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methods of collecting information and noted that the report was being developed further to include this information.
9.10 CG expressed concerns regarding the relaxation of the CQC inspection regime and felt that standards could fall which would place a greater emphasis on the CCG to review its monitoring arrangements in order to seek assurance. MAE concurred and reminded members that as commissioners, the CCG had a legal obligation to seek assurance on quality arrangements.
9.11 HG advised that a data review exercise would be undertaken by the CCG in order to triangulate all the information held for practices and correlating this with information held by the CQC.
9.12 DB suggested if the practices could identify best practice which could be shared with other practices who were awaiting inspections. AS suggested that a guidance document was established which could be shared with practices.
9.13 HG advised that a buddying approach had proven to be successful for practices and that Bronwyn Barnes was developing this into a model.
9.14 RESOLUTION: The Committee noted the report.
10 General Practice Forward View Investment Plan
10.1 HG presented the report which provided an update on the response to the General Practice Forward View and supported the 30,000 place-based model.
10.2 HG advised that the General Practice Forward View sets out a range of investments in primary care and makes a commitment that CCGs would provide £171 million of practice transformational support.
MW joined the meeting at 12.06
10.3 HG stated that the General Practice Forward View reflected the ambitions of the Sustainability and Transformation Plan (STP) and the Five Year Forward View in terms of developing a practice
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resilience program. HG articulated that this did not suggest practice mergers and primarily related to supporting a collaborative and integrated work approach i.e. sharing workforce and administrative functions.
10.4 HG advised that all practices were invited to collaborate into groups, or “clusters”, with a total registered list size of 30,000 patients or more to develop an expression of interest for innovative, transformative ideas that improved patient outcomes along with the sustainability of primary care and the wider Gloucestershire health economy.
10.5 HG explained that 15 ‘clusters’ had been established by the 81 practices converging and bringing their localities to form the clusters which was outlined in Page 2 of the report. HG highlighted that these were not contractual clusters but practices working together ‘at scale’ which had geographical or demographical alignment.
10.6 HG advised that that 14 bids had been received which could be categorised into the following themes. These were:
clinical pharmacists in primary care; urgent care; and frailty provision.
10.7 HG advised that mental health also feature as part of the proposed scheme for Gloucester and that the focus was to keep patients at home, improve quality and safety and as a result reduce spend across the healthcare system.
10.8 CG highlighted that one cluster had yet to submit a bid and queried if the funding value took account of this. HG confirmed that this was covered within the funding allocation.
10.9 RESOLUTION: The Committee noted the report
11 Any Other Business
11.1 AS informed members on the Gloucestershire CCG Annual Assurance 2015/16 and reported that Gloucestershire CCG was
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rated as ‘good’ overall and that the delegated commissioning component was rated as ‘outstanding’. Members noted that Gloucestershire CCG was the only CCG in the country to receive ‘outstanding’ for delegated commissioning. The Committee congratulated the CCG and the Primary Care Team for this achievement.
12 The meeting closed at 12:18.
13 Date and Time of next meeting: Thursday 29th September 2016 in the Board Room at Sanger House.
Minutes Approved by Gloucestershire Clinical Commissioning Group Primary Care Commissioning Committee:
Signed (Chair):______Date:______
Page 12 of 12 PCC Committee Minutes 28/07/16
Agenda Item 19
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Priorities Committee minutes Executive Summary The attached minutes provide a record of the Priorities Committee meeting held on the 7th July 2016.
Key Issues The following principal issues were discussed:
Scoring Outcomes; and SIP feeds.
Risk Issues: Not applicable Original Risk Residual Risk Financial Impact Not applicable
Legal Issues (including Not applicable NHS Constitution) Impact on Health None Inequalities Impact on Equality and None Diversity Impact on Sustainable None Development Patient and Public Not applicable Involvement Recommendation The Governing Body is requested to note these minutes which are provided for information. Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director Alan Elkin (if not author) Vice Chair and Lay Member
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Priorities Committee
Minutes of the Meeting held at 2.00 p.m. On Thursday 7th July 2016 in the Board Room, Sanger House
Present: Alan Elkin (AE) Lay Member - PPE and Vice Chair Mary Hutton (MH) Accountable Officer Marion Andrews-Evans (MAE) Executive Nurse and Quality Lead Julie Clatworthy (JC) Registered Nurse Dr Raju Reddy (RR) Secondary Care Doctor Sarah Scott (SS) Director of Public Health Joanna Davies (JD) Lay Member - PPE Dr Malcolm Gerald (MGe) GP Liaison Lead – South Cotswolds Locality Colin Greaves (CG) Lay Member - Governance Dr Will Haynes (WH) GP Liaison Lead - Gloucester City Locality Dr Caroline Bennett (CBe) GP Liaison Lead - North Cotswolds Locality Dr Charles Buckley (CBu) GP Liaison Lead - Stroud and Berkeley Vale Locality Dr Tristan Lench (TL) GP Liaison Lead - Forest Locality Dr Hein Le Roux (HLR) Deputy Clinical Chair Ellen Rule (ER) Director of Transformation and Service Redesign Mark Walkingshaw (MW) Director, Commissioning Implementation Dr Reddy Raju (RR) GP Secondary Care Dr Jeremy Welch (JW) GP Liaison Lead - Tewkesbury Locality
In Attendance: Andrew Beard (AB) Deputy Chief Finance Officer Mark Gregory (MGr) Medicines Management Lead Alan Potter (AP) Corporate Governance Support Officer Charlotte Waddon (CW) Board Administrator Sarah Alan (SA) ST3 Trainee GP Sadie Trout (ST) Head of Planning
1. Apologies for Absence
1.1 Apologies were received from; Cath Leech, Dr Andy Seymour and Margaret Wilcox.
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2. Declarations of Interest
2.1 There were no declarations of interest.
3. Minutes of the Meeting held on the 19th May 2016
3.1 The minutes of the meeting were accepted as a true and correct record, subject to the following amendment:
Section 6.8.10 to be amended to read ‘Resolution: The Committee voted unanimously in favour of the proposal for the restriction of non-generic sildenafil prescribing for erectile dysfunction. This would include the addition of non-sildenafil drugs as an IFR and supporting prescribing guidance and policy documentation would be developed.’
4. Matters Arising
4.1 North Cotswold Clinical Pharmacists 28th April 2016 Item 6.17: AE informed that the pilot should be monitored in September to track performance and that any remedial actions could be undertaken systematically if this was necessary.
4.2 SIP Feeds 19th May 2016 Item 6.7.9: It was noted that further discussions had taken place and were reflected in the Priorities Meeting agenda. The outcome of this item was agreed in principle by way of FP10’s but requiring further consideration of the details involved. This was covered under Agenda Item 6. Item Closed.
4.3 Improving Access to Psychological Therapies (IAPT) 19th May 2016 Item 10.4: MW stated that there was a lack of source for funding. MH informed that 2Gether Trust had requested for a proposal of £600k in order to achieve the target in addition to the £300k. MH informed that there would be a paper brought to a future meeting.
5. Scoring Outcomes
5.1 ER made a presentation which provided an overview of the following points below: recap of scoring from the 19th May; financial position of each of the agreed commitments; and scoring outcomes. Page 2 of 4
5.2 It was noted that the Crisis Café had been approved for a one year funding pilot and that information was to be sent to the Governing Body. MW advised that Home Enteral Feeding Team issues were in the process of being resolved.
5.3 WH questioned the ranking of the proposals with a particular regard to investments and disinvestments. ER acknowledged that there would be a clear distinction of investments and disinvestments in the schedule going forward.
5.4 Resolution: Members noted the completed scoring matrix and accepted these as the final scores and ranked position for the five investment/disinvestment proposals presented on 19th May 2016.
6. SIP Feeds Update
6.1 MGr made a presentation which explained further discussions at the last meeting regarding SIP Feeds. The presentation covered: a summary of previous discussions; details of patient numbers; benefits of this Proposal; background/Evidence; savings; and risks/issues implementation.
6.2 MG informed the group that Teresa Middleton and CBu had met with the GHT dietitians to discuss the proposal. It was noted that nationally a number of CCG’s were no longer recommending the prescribing of Gluten free products on FP10 but none had applied similar restrictions for SIP Feeds on FP10.
6.3 AE questioned if the IFR procedure would be part of the process. CBu advised that it would need to be tested but that was the intention. ER agreed stating that it would not be routine, only for exception situations.
6.4 JC questioned what SIP Feed options were available for children. CBu responded that it would be through medical indication or the advice of a dietitian.
6.5 RR enquired about the costing of SIP Feeds and suggested Page 3 of 4
providing a sample to patients. CBu stated that this could cause complications and that GP’s could find it difficult to ask patients to start paying for the Feeds that they had previously received on prescription.
6.6 JD suggested introducing a pilot in practices to gather further information. ER responded that it would be useful to have a team working in the community who could provide dietary advice and suggestions. JD considered that the outcome of stopping the current prescribing of sip feeds in practice would be uncertain and by testing a pilot, the CCG would be able to the assess likely impact.
6.7 JC enquired as to who would host the Dietetic Team. CBu stated that the dietitians are already being stretched and felt that there would be benefits in linking with the Acute Trust. MW agreed that such links would be needed.
6.8 MAE suggested that it would be useful to work with the South Cotswolds practices for piloting as there would be links with the frailty assessment. MG explained that the aim was to develop more support and skills for staff that were seeing patients.
7.0 Resolution
The Committee agreed:
that in principle, GP’s should stop prescribing SIP Feeds by way of FP10’s; to explore the provision of a Community Dietetic team to provide education, training advice and prescribing guidance. exceptional cases would be referred via the IFR process Fast-track decisions are possible (Several days) GP to submit case for IFR authorisation
8.0 Any Other Business
8.1 There was no future business.
The meeting closed at 15:15pm. Date and time of next meeting: Thursday 22nd September 2016 at 2pm in the Boardroom, Sanger House.
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Agenda Item 20
Governing Body
Governing Body Thursday 24th November 2016 Meeting Date Title Joint Commissioning Partnership Board Minutes Executive Summary The attached minutes provide a record of the Joint Commissioning Partnership Board meeting held on the 7th June 2016. Key Issues The following principal issues were discussed:
Joint Commissioning Partnership Finance Report; Better Care Fund update and Risk Register; and Mental Health.
Risk Issues: Not applicable Original Risk Residual Risk Financial Impact Not applicable Legal Issues Not applicable (including NHS Constitution) Impact on Health None Inequalities Impact on Equality None and Diversity Impact on Sustainable None Development Patient and Public Not applicable Involvement Recommendation The Governing Body is requested to note these minutes which are provided for information. Author Alan Potter Designation Associate Director of Corporate Governance Sponsoring Director Mary Hutton (if not author) Accountable Officer
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Gloucestershire County Council & Gloucestershire Clinical Commissioning Group Joint Commissioning Partnership Board (JCPB) Tuesday 7th June, 2016 9:00am – 10:00am Members Room, Shire Hall
Minutes These minutes may be made available to public and persons outside of the Gloucestershire NHS and Gloucestershire County Council community as part of the community’s compliance with the Freedom of Information Act Present: Cllr. Paul McLain (Chair) PMcL Cllr. Dorcas Binns DB Kim Forey KF Dr Andrew Seymour HM Sarah Scott SS Linda Uren LU Mary Hutton MH Margaret Willcox MW
In Attendance: Anne Mellor (Minutes) AM
Apologies: Cath Leech CL Jo Walker JW Mark Walkingshaw MWa
1.0 Apologies Apologies were received from Cath Leech, Jo Walker and Mark Walkingshaw.
2.0 Minutes from the last meeting and Matters Arising
The minutes from the last meeting held on 10th December 2015 were agreed as a true record.
Action 001: JCP Finance Report – Vikki Walters, Karl Gluck and Jennifer Taylor to be invited to JCPE to discuss where the issues are, areas for priority and other opportunities. Work is ongoing.
Action 002: JCP Finance Report - Question for JCPB ‘Are we commissioning effectively for mental health services? LU advised that work is underway and regularly monitored by JCPE.
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Action 003: GSF Transformation update to be included in JCPB agenda.
Linda Uren (LU) reported that the Transformation Plan had been accepted.
3.0 Joint Commissioning Partnership Finance Report .
Mary Hutton went through the JCP Finance report reflecting the year end position for 2015/16.
The net variance across all agreements is an overspend of £2.646m.
The significant variances and movements are;
£0.325m net overspend within the BCF. This is due to:-
£0.022m net overspend on GCC-Commissioned services: £0.152m overspend on Hospital Rapid Discharge (HRD) beds, offset by £0.130m underspend on the Carers service.
£0.303m net overspends on CCG-Commissioned Services:
o Acute (£2.405m). The overspend reflects the Performance Fund which is driven by increases in emergency activity during the year. o Community (-£2.285m). This primarily relates to slippage on staff appointments relating to the Integrated Community Team service which is now up to full establishment. o Mental Health (0.193m). This relates to increased coverage of mental health liaison services within the acute hospital.
£0.695m overspend relating to S256 LD and PD joint funded care, CHC and private sector placements. S256 Telecare budgets are forecast are forecast to be overspent by £0.149m. This is due to increased staffing and equipment purchases, following expansion of the service. S75 Community Equipment Services (CES) has a £1.228m overspend. This is a significant amount, and a piece of work is currently being done by Donna Miles.
Detailed plans are underway in each of the areas which are overspent, and are being closely monitored by JCPE each month.
4.0 BCF Update & Risk Register – Margaret Willcox Margaret Willcox advised that the BCF plan has been submitted for Gloucestershire, and has received very positive feedback. She expressed her thanks to Mary Morgan for all her hard work on this.
MW had circulated the BCF plans for other areas who have received good feedback for information. These were from Bath and North East Somerset (BANES), Dorset, and Bournemouth and Poole.
All plans are now in the assurance process, and are awaiting confirmation of approval.
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5.0 Mental Health . MW advised that there are currently two pieces of work underway to support people with Mental Health issues. Perinatal Mental Health and Personality Disorders are the two main areas of focus.
There is a review of support services for people with lower demand needs. Kath Rees and Colin Merker are looking at supported living schemes for people who have come out of long term placements.
Every individual is being reviewed, with a dedicated Social Worker looking into the support needed. This will range from support for general daily skills to a full support service. They are looking at what is the right service to commission.
LU advised that we have good Mental Health providers looking after the more serious cases. Focus is needed on the people with less obvious needs. These people are difficult to look after, as they fall between having serious Mental Health needs and not having a diagnosable mental illness. LU is looking at the 18 – 25 year old cohort to identify their issues.
MH advised that she has met with psychiatrists, who are keen to see changes made and identify where the services are available. Work is currently being done in Gloucester City on this.
Karl Gluck is currently working on commissioning support drop-ins. This is at the consultation stage. The idea is to have more people in them for shorter periods of time.
KF outlined a plan for improving perinatal and infant Mental Health outcomes in Gloucestershire. This is a place based approach, looking at the structure in communities. Parents often have mental health issues and the knock on effect is significant. Not having a proper bond between a mother and her child has a significant long term impact.
KF to circulate a copy of the paper which has been circulated to GP practices to promote this strategy..
ACTION 001: KF to forward a copy of the document for circulation by AM
The Perinatal Health Issues paper has been presented to the Mental Health Partnership Board.
KF stated that we have statutory obligations with regard to Homeless people, and this requires a different approach.
SS advised that KR wants to bring a paper to JCPE for consideration regarding Assertive Outreach. We need a countywide approach.
6. AOB
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The meeting was cancelled in April due to the number of apologies received, and LU circulated the Integrated Commissioning paper virtually, which was agreed.
LU advised that there was currently an OFSTED inspection of the SEND underway. KF advised that, following Simon Bilous’ decision to take flexible retirement, Helen Ford has been appointed to job share with Simon.
Date of Next Meeting: TBC September 2016
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Table of Actions
Agenda Item Action No. Action: Lead Status
5. Mental Health 001 KF to provide a copy of the paper which has been circulated to KF/AM GP practices to promote the Improving Perinatal and Infant Mental Health strategy. AM to circulate.
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