AGENDA NHS Leeds CCG Governing Body Meeting – Circulation of Papers

Item Description Lead Paper Time GB Welcome and Apologies Gordon Sinclair N N/A 19/120 Purpose: To record apologies for absence and confirm the meeting is quorate. GB Declarations of Interest Gordon Sinclair Y 19/121 Purpose: To record any Declarations of Interest relating to items on the agenda:

a) Financial Interest Where an individual may get direct financial benefit from the consequences of a decision they are involved in making;

b) Non-Financial professional interest Where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making;

c) Non-financial personal interest Where an individual may benefit personally in ways that are not directly linked to their professional career and do not give rise to a direct financial benefit, because of the decisions they are involved in making; and

d) Indirect Interests Where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making. GB Questions from Members of the Public Gordon Sinclair N N/A 19/122 Purpose: To receive questions from members of the public GB Minutes of the Governing Body Meeting held on 29 Gordon Sinclair Y N/A 19/123 January 2020

Purpose: To receive the minutes for approval GB Matters Arising Gordon Sinclair N 19/124 Purpose: To consider any matters arising that are not considered elsewhere on the agenda

GB Action Log Gordon Sinclair Y 19/125 Purpose: To review the outstanding actions

Item Description Lead Paper Time RISK GB Corporate Risk Register Sabrina Y N/A 19/126 Armstrong Purpose: To receive the corporate risks for review

GB Governing Body Assurance Framework Sabrina Y 19/127 Armstrong Purpose: To receive the Governing Body Assurance Framework for review

STRATEGY GB CCG Operating Plan & 2020/21 Budgets Sabrina Y N/A 19/128 Armstrong Purpose: To receive the plan and budgets for approval /Visseh Pejhan Sykes GB Health Inequalities Framework Katherine Y N/A 19/129 Sheerin Purpose: To note the updated health inequalities framework for action COMMITTEE CHAIRS SUMMARIES GB Primary Care Commissioning Committee – 5 February Sam Senior Y N/A 19/130 2020

Purpose: To receive the summary for information and assurance

GB Remuneration & Nomination Committee – 13 February Sam Senior Y 19/131 2020

Purpose: To receive the summary for information and assurance

GB Quality & Performance Committee – 13 March 2020 Phil Ayres Y 19/132 Purpose: To receive the summary for information and assurance COMMISSIONING & FINANCE GB Integrated Quality & Performance Report (IQPR) Helen Lewis/ Y N/A 19/133 Katherine Purpose: To receive the IQPR and consider any issues Sheerin escalated by the Quality & Performance Committee

GB Finance Report Visseh Pejhan- Y N/A 19/134 Sykes Purpose: To receive the finance report for information

GB Chief Executive’s Report Tim Ryley Y N/A 19/135 Purpose: To receive an update on key issues from the CCG’s Chief Executive GOVERNANCE GB Staff Survey Results & Action Plan Sabrina Y N/A 19/136 Armstrong Purpose: To receive the results of the staff survey and the action plan Item Description Lead Paper Time GB Policy Approval 19/137 Katherine N/A i. Rebate Policy Sheerin Y

Purpose: To approve the policy

GB Questions from Members of the Public Gordon Sinclair N N/A 19/138 Purpose: To receive questions from members of the public

GB Forward Work Programme 2020/21 Gordon Sinclair Y N/A 19/139 Purpose: To receive the draft forward work programme for 2020/21

GB Any Other Business Gordon Sinclair N N/A 19/140 Exclusion of the public - it is recommended that the following resolution be passed: "That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest"

Confidential Section - Held in private GB Confidential Minutes of the Governing Body held on 29 Gordon Sinclair Y N/A 19/141 January 2020

Purpose: To receive the minutes for approval

GB Remuneration & Nomination Committee Sam Senior Y N/A 19/142 a) Approval of recommendation

Purpose: To consider the recommendation for approval

b) Ratification of urgent decision

Purpose: To ratify the urgent decision

GB Procurement Update Visseh Pejhan- Y N/A 19/143 Sykes a) Tender Evaluation Report - Community Chronic Pain Service

Purpose: To approve the tender evaluation report

b) Tender Evaluation Report – Cluster Based Support Purpose: To approve the tender evaluation report

GB Finance Update Visseh Pejhan- Y N/A 19/144 Sykes a) Review of LTHT Support Purpose: To approve the additional support to LTHT

b) ICS Financial System Item Description Lead Paper Time

Purpose: To receive and comment on the report. ITEMS FOR INFORMATION

Dates of Future Meetings:  Wednesday 20th May 2020  Wednesday 22nd July 2020  Wednesday 23rd September 2020  Wednesday 25th November 2020  Wednesday 27th January 2021  Wednesday 24th March 2021 RegisterofInterestsv2-0 Title Name Job Title Role Practice B Code Declared Interest- (Name of the organisation and nature of business) Type of Interest Is the Interest From Interest Until Action Taken to Mitigate Risk (where applicable) (Practice Only) interest direct or indirect? Angela Collins Lay Member for Patient and Public Governing Body N/A Nil Declaration Participation Member Dr Ben Browning Member Representative Governing Body B86020 GP Partner at Lofthouse Surgery Financial Interests Direct 01/02/2019 01/04/2020 Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Ben Browning Member Representative Governing Body B86020 Shareholder in Leodis Care Ltd (now dormant) Financial Interests Direct 01/01/2011 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Ben Browning Member Representative Governing Body B86020 Member of Leodis Care LLP (Shell Company) Financial Interests Direct 01/01/2011 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Ben Browning Member Representative Governing Body B86020 Spouse is a Salaried GP Indirect Interests Indirect 01/01/2019 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Ben Browning Member Representative Governing Body B86020 Spouse is city-wide lead for Disability Services (NHS Leeds CCG) Indirect Interests Indirect 01/01/2015 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Gordon Sinclair GP Partner / Clinical Chair Governing Body B86030 GP Partner at Burton Croft Surgery Financial Interests Direct 01/01/1993 Ongoing Declare conflict or perceived conflict within Member context of any relevant meeting or project work Dr Gordon Sinclair GP Partner / Clinical Chair Governing Body B86030 Burton Croft Surgery is a shareholder of Leeds West Primary Care Network Ltd. Financial Interests Direct 01/01/2016 Ongoing Declare conflict or perceived conflict within Member context of any relevant meeting or project work Dr Gordon Sinclair GP Partner / Clinical Chair Governing Body B86030 Partner of Viva Healthcare LLP Financial Interests Direct 01/01/2012 Ongoing Declare conflict or perceived conflict within Member context of any relevant meeting or project work Helen Lewis Interim Director of Acute and Governing Body N/A Trustee, Leeds Jewish Welfare Board Non-Financial Personal Interests Direct 01/12/2017 Up to 9 year Declare any potential or perceived conflict of Specialised Commissioning. Member term interest at relevant meetings/workshops Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Partner at Oakwood Lane Medical Practice Financial Interests Direct 01/01/2006 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Director Jemjo Healthcare Ltd Financial Interests Direct 01/05/2007 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Spouse business Airtight International Ltd Indirect Interests Indirect 10/05/2012 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Spouse business Nails 17 Ltd Indirect Interests Indirect 10/05/2012 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Director Leeds Jewish free school Non-Financial Personal Interests Direct 16/01/2014 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Director/trustee Brodetsky Primary School Foundation Non-Financial Personal Interests Direct 17/06/2014 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Chair of Governor's Brodetsky Primary School Non-Financial Personal Interests Direct 01/09/2012 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Founding Fellow of the Faculty of Clinical Informatics Non-Financial Professional Interests Direct 01/05/2018 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Gartner UK - Clinical Advisor Financial Interests Direct 01/06/2018 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Calibre Care Partners Ltd OLMP is a member of this GP federation, which is part Financial Interests Direct 01/06/2018 Ongoing Declare any potential conflict/interest at relevant Member of Leeds GP Confederation Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Shareholder / Director Chapeloak Services Ltd Financial Interests Direct 01/01/2019 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Leeds Acupuncture Clinic - father's and brother's business Indirect Interests Indirect 10/05/2012 Ongoing Declare any potential conflict/interest at relevant Member Governing Body/Committee meetings

Dr Jason Broch Assistant Clinical Chair Governing Body B86022 Clinical Lead - Yorkshire & Humber Local Health & Care record Exemplar, inc Financial Interests Direct 01/11/2018 Ongoing Declare any potential conflict/interest at relevant Member membership of NHSE Clinical Advisory Group Governing Body/Committee meetings

Joanne Harding Executive Director of Quality and Governing Body N/A Joint Chair of the NHSCC National Nurses Forum Non-Financial Professional Interests Direct 01/07/2019 Ongoing Declare any conflict of interest at relevant Safety/Governing Body Nurse Member meetings/workshops. Dr Julianne Lyons GP Member Representative Governing Body B86110 GP Partner at Leeds Student Medical Practice Financial Interests Direct 01/01/2016 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Leeds Local Medical Committee Member Financial Interests Direct 01/09/2013 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Spouse is a Director of Leeds Haematology Ltd Indirect Interests Indirect 01/05/2013 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Spouse is a trustee of UK Myeloma Forum Indirect Interests Indirect 01/01/2013 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Spouse is an employee of the University of Leeds Indirect Interests Indirect 01/01/2015 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 GP lead for Leeds Primary Care Workforce and Training Hub Financial Interests Direct 01/05/2018 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Spouse has an honorary contract with Leeds Teaching Hospitals NHS Trust Indirect Interests Indirect 01/01/2015 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 Shareholder of Leeds West Primary Care Limited Financial Interests Direct 01/10/2015 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Julianne Lyons GP Member Representative Governing Body B86110 I am a member of LSMP and The Light PCN Financial Interests Direct 01/07/2019 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops Dr Julianne Lyons GP Member Representative Governing Body B86110 Daughter employed by Leeds Student Medical Practice. Project Co-ordinator for Indirect Interests Indirect 01/07/2019 Ongoing Declare any potential or perceived conflict of Member Leeds Primary Care Workforce Hub. interest at relevant meetings/workshops. Katherine Sheerin Director of System Integration Governing Body N/A Director, Ambition Health Ltd (Health consultancy service) Financial Interests Direct 30/09/2017 Ongoing Ambition Health Ltd not to bid for or undertake (Interim) Member work in the West Yorkshire and Harrogate area. Explicit permission from CCG CEO for any work to be undertaken. Katherine Sheerin Director of System Integration Governing Body N/A Part of the role of Director of System Integration is to work for the NHS Providers Non-Financial Professional Interests Direct 01/04/2019 31/12/2019 Declare any interest/potential interest at relevant (Interim) Member in Leeds to support integration of services. The role is part funded by these meetings/workshops. If relevant decisions to be providers as follows - Leeds Community Healthcare NHS Trust; Leeds Teaching taken, meeting Chair to check with Conflicts of Hospitals NHS Trust; Leeds and York Partnerhsip NHS Foundation Trust; Leeds GP Interest Guardian/ Head of Corporate Governance Confederation. whether further actions are required. KS not to be involved in any procurement decisions/processes. Attendance at Governing Body and other committees will be in a non-voting capacity.

Katherine Sheerin Director of System Integration Governing Body N/A Member of the Institute of Health Management Executive Board Non-Financial Professional Interests Direct 13/09/2019 31/12/2019 Declare any potential conflict of interest at (Interim) Member relevant meetings with the CCG Dr Keith Miller GP Member Representative Governing Body B86109 GP Partner at Kirkstall Lane Medical Centre Financial Interests Direct 01/01/2010 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Dr Keith Miller GP Member Representative Governing Body B86109 NHs Leeds Clinical Commissioning Group – Member Representative Financial Interests Direct 01/01/2018 Ongoing Declare any potential conflict of interest at Member Governing Body/Board, sub committees and relevant meetings Phil Ayres Secondary Care Consultant and Governing Body N/A Personal friendship with the Chief Executive of Leeds Community Healthcare Indirect Interests Indirect 27/11/2019 Ongoing The action required to manage any conflicts of Chair of the Quality and Member interest will be agreed with the Chair of the Pewrformance Committee relevant meeting. In relation to the Quality and Performance Committee which I chair, the Deputy chair will be asked to agree any required actions. No confidential/sensitive information to be shared or discussed with the LCH Chief Executive.

Phil Ayres Governing Body Member Governing Body N/A I have personal friendships with GP of the Rawdon Surgery Indirect Interests Indirect 01/01/2017 Ongoing Maintain awareness of potential influence over Member decisions I may take as independent practitioner. Abide by GMC code of conduct. Declare this interest at relevantmeetings.

Sabrina Armstrong Director of Organisational Governing Body N/A Personal friendship with a non-executive director of Leeds Community Healthcare Non-Financial Personal Interests Direct 01/05/2019 Ongoing Declare any potential or perceived conflict of Effectiveness Member NHS Trust. interest at relevant meetings/workshops. Sabrina Armstrong Director of Organisational Governing Body N/A Close friend works as Director of System Capability and Operations at NHS Indirect Interests Indirect 01/01/2014 Ongoing Declare any potential or perceived conflict of Effectiveness Member England. interest at relevant meetings/workshops. Sabrina Armstrong Director of Organisational Governing Body N/A Pool member with NHS Interim Management and Support (NHS IMAS). Non-Financial Professional Interests Direct 01/01/2014 Ongoing Declare any potential or perceived conflict of Effectiveness Member interest at relevant meetings/workshops. Sam Senior Lay Member for Primary Care Co- Governing Body N/A Lay Member for Primary Care Bassetlaw CCG Financial Interests Direct 01/09/2013 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Lay Representative National School of Healthcare Science Financial Interests Direct 01/05/2016 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Lay Advisor Health Education England (West Midlands) Financial Interests Direct 01/05/2016 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Patient and Public Panel Member - National Institute Health Research Financial Interests Direct 01/04/2017 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Chairperson - Brampton United Junior Football Club (S63 6BB) Non-Financial Personal Interests Direct 01/05/2013 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Independent Lay Member to Rotherham Federation Connect Healthcare Non-Financial Professional Interests Direct 29/05/2019 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Non-Exec Director Rotherham Federation Connect Healthcare Non-Financial Professional Interests Direct 29/03/2019 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Sam Senior Lay Member for Primary Care Co- Governing Body N/A Volunteer of Corton Wood Miners Welfare Trust (S730TU) Non-Financial Personal Interests Direct 15/10/2019 Ongoing Declare any potential or perceived conflict of Commissioning Member interest at relevant meetings/ workshops Dr Simon Stockill Medical Director Governing Body N/A Partner at Sleights and Sandsend Medical Practice, Whitby (Hambleton, Financial Interests Direct 01/04/2016 Ongoing Declare any conflict or perceived conflict within Member Richmondshire & Whitby CCG) context of any relevant meeting or project work

Dr Simon Stockill Medical Director Governing Body N/A GP Appraiser, NHS England (Yorkshire & Humber) Financial Interests Direct 01/12/2013 Ongoing Declare any conflict or perceived conflict within Member context of any relevant meeting or project work

Dr Simon Stockill Medical Director Governing Body N/A Clinical Lead for Quality Improvement, Royal College of GPs Financial Interests Direct 01/09/2016 Ongoing Declare any conflict or perceived conflict within Member context of any relevant meeting or project work

Dr Simon Stockill Medical Director Governing Body N/A Clinical Director, Whitby Coast & Moors Primary Care Network Financial Interests Direct 01/07/2019 Ongoing Declare any conflict or perceived conflict within Member context of any relevant meeting or project work

Susan Brear Lay Member for Audit and Conflict Governing Body N/A This however is not related in any way to the NHS or the CCG and has no Financial Interests Direct 01/05/2019 01/02/2021 Declare any potential or perceived conflict of of Interest Member implications on any decisions I may be required to make in my CCG roles. I mark interest at relevant meetings/workshops Business and Economic exam scripts at a degree level for the Chartered Insurance Institute and on an adhoc basis assess and write exam questions for a professional accounting body. Tim Ryley Chief Executive Officer Governing Body N/A Nil Declaration Member Visseh Pejhan-Sykes Chief Finance Officer Governing Body N/A Niece works for CCG as Digital Communications Officer Indirect Interests Indirect 11/12/2017 Ongoing Declare any potential or perceived conflict of Member interest at relevant meetings/workshops

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Draft Minutes NHS Leeds CCG – Governing Body Meeting Wednesday 29 January 2020 1.30pm – 5.00pm Pudsey Civic Hall, Dawsons Corner, Leeds, LS28

Members Initials Role Present Apologies Dr Gordon Sinclair (Chair) GS Clinical Chair  Dr Phil Ayres PA Secondary Care Specialist Doctor  Sue Brear SB Lay Member – Audit & Conflicts of Interest  Dr Jason Broch JB Assistant Clinical Chair  Dr Ben Browning BB Member Representative  Angela Collins AC Lay Member – Patient & Public Involvement  Jo Harding JH Executive Director of Quality and Nursing  Dr Julianne Lyons JL Member Representative  Dr Keith Miller KM Member Representative  Visseh Pejhan-Sykes VPS Executive Director of Finance  Tim Ryley TR Chief Executive  Samantha Senior (Deputy SS Lay Member – Primary Care Co-  Chair) Commissioning Dr Simon Stockill SSt Medical Director  Dr Ali Best (deputising for AB Associate Medical Director Dr Simon Stockill)  Additional Attendees Sabrina Armstrong SA Director of Organisational Effectiveness  Dr Ian Cameron IC Director of Public Health  Dylan Roberts DR Chief Digital and Information Officer  HL Interim Director of Acute & Specialist  Helen Lewis Commissioning Katherine Sheerin KS Director of System Integration  Laura Parsons LP Head of Corporate Governance & Risk  Sam Ramsey SRa Corporate Governance Manager  CB  Caroline Baria Deputy Director, Integrated Commissioning (item 19/102) TS  Tim Sanders Commissioning Manager, Dementia (item 19/03)

Members Initials Role Present Apologies JS  John Scott Head of People & OD (item 19/04)

Members of the Public Observing the Meeting – 3

No. Agenda Item Action GB Welcome and Apologies 19/94 GS welcomed everyone to the Governing Body meeting. Apologies were received on behalf of JL. Dr Ali Best was deputising on behalf of SS.

The Chair welcomed HL to her first Governing Body meeting as interim Director of Acute & Specialised Commissioning.

The Chair confirmed that the meeting was quorate.

GB Declarations of interest 19/95 Members were asked to raise any declarations of interest in relation to agenda items.

JB highlighted that in relation to one of his interests, work was being undertaken for an STP relating to Population Health Management. This would be added to the register.

No further items were raised.

GB Questions from Members of the Public 19/96 The meeting was opened up to the public to take any questions they had at this stage.

A member of the public requested further information relating to the Leeds position in terms of national targets in relation to both cancer and A&E performance. It was acknowledged that a detailed response may not be available at the meeting and a written response was requested.

The specific targets highlighted were in relation to the 2 month wait from GP urgent referral to first treatment for cancer and the 2 month wait following a consultant decision to upgrade the case priority to a first treatment for Cancer. In addition to this, the A&E 4 hour wait target and the number of patients spending more than 4 hours from decision to admit to admission was also raised.

The Chair acknowledged that these targets were high on the CCG agenda and considered and discussed at the Quality & Performance Committee. It SRa/HL was agreed that a written response would be sent to the member of the public following the meeting.

No. Agenda Item Action GB Minutes from Previous Meetings 19/97 GS presented the minutes from the NHS Leeds Governing Body held on 27 November 2019 for approval.

The Governing Body: (a) approved the minutes of the NHS Leeds Governing Body held on 27 November 2019. GB Matters Arising 19/98 There were no matters arising.

GB Action Log 19/99 The Governing Body reviewed the action log and noted the following updates:

19/68 – The revised Procurement Policy and plan would be discussed at the Audit Committee in April and return to the May Governing Body meeting

All other actions were complete.

GB Corporate Risk Register 19/100 SA presented the report and highlighted that there had been no changes to the risk register since the last iteration. There were no red risks for the Governing Body to consider.

The Governing Body: a) noted the risk register.

GB Governing Body Assurance Framework (GBAF) 19/101 SA presented the GBAF for the Governing Body to review, highlighting that lead Directors had reviewed and updated their risks. Members acknowledged that the risk management strategy included a review of assurances provided by the GBAF and the Audit Committee would review this at each meeting. The Audit Committee had received Risk 3 at the last meeting and this would be discussed through the Audit Committee Chairs Summary (item GB 19/107).

Following previous discussions at the Governing Body, there was a suggestion that risk 6 was broadened to reflect the challenges across the wider workforce. Members were informed that this would be considered as part of the annual GBAF process. The review was underway and would be discussed at EMT and then return to the Governing Body in May 2020.

A query was raised in relation to risk 4 and the potential fragility of PCNs and risk that practices don’t engage and whether this should be reflected in the risk. Members were informed that a PCN Clinical Director session had taken place with the CCG to consider alignment and what local decision making would look like. The session had considered the risk of practices withdrawing

and a collaborative approach was discussed. JB assured members that there was a level of commitment from the PCN Clinical Directors and CCG in relation to locality working and there was acknowledgement that there was a

No. Agenda Item Action need for a stable platform in primary care.

A further query was raised in relation to risk 5 and attracting workforce to areas of greater deprivation. It was recognised that this could be factored in further to the health inequalities framework. An example was provided of work that had been done in Lincoln Green and there was an intention to roll this out across Leeds.

The Committee discussed the review of risk 6 and the timing of this being

presented to the Audit Committee. It was agreed that TR and SB would discuss this outside of the meeting. TR/SB

The Governing Body: a) reviewed the Governing Body Assurance Framework; b) considered whether the controls and assurances are sufficiently robust; c) agreed there were no further actions required to manage the risks to the target set; and d) noted the review and assurance processes.

GB Leeds Mental Health Strategy 19/102 TR provided an overview on the four strategy items to be presented to the Governing Body. It was highlighted that although each document was different, they were all valuable and it was important to consider each document in their own right.

HL presented the Leeds Mental Health Strategy and welcomed Caroline Baria who was in attendance for any questions related to the strategy. The Governing Body was informed that this was an all-age strategy covering how Leeds plans to improve mental health and wellbeing from conception through to end of life. The Governing Body was being asked to endorse the vision and ambitions and priorities contained within it. Members acknowledged that the strategy would then be presented to the Health & Wellbeing Board in February 2020 for final sign off.

Members were informed that a delivery plan was in place which highlighted where partners were accountable. This would also be used in commissioning planning.

The Chair iterated to members that the strategy was not a CCG strategy but a city strategy that the CCG was being asked to sign up to and comment upon.

A query was raised in relation to the approach within the organisation around mental health and wellbeing for staff. SA assured members that there was a focus on this internally and there had recently been 11 members of staff trained as mental health first aiders.

No. Agenda Item Action A further query was raised in relation to the absence of drug and alcohol services within the strategy. CB informed members that there was recognition that the Mental Health Strategy was not the only strategy and there was a range of other strategies across health and social care that could link directly into the Mental Health strategy. IC highlighted that there was a partnership drug and alcohol strategy, the linkages across the two were recognised and it was important not to operate in silos.

The importance of community development was raised and members were informed that the delivery plan highlighted the number of third sector organisations involved.

A query was raised in relation to how the passions, priorities and outcomes connect. It was iterated that the strategy had been prioritised based on the Health & Wellbeing strategy in relation to Mental Health. The feedback was helpful and would be considered when learning from the strategy for future work.

In relation to page 14 of the strategy, ‘what will a Mentally Healthy Leeds look like in 5 years?’, it was queried how this would be measured and who would assess this. It was suggested that the wording was amended to read what it would look like in the future rather than a specified timescale.

HL expressed thanks to Sarah Erskine, Public Health for all the hard work on the strategy.

TR welcomed the comments and highlighted that this would link to the CCG becoming strategic commissioners and would be part of the challenge that the CCG would face to act in a more strategic way.

The Chair summarised that this was a broad overarching strategic document and was helpful to see the approach to the indicators.

The Governing Body: a) received and endorsed the new Mental Health Strategy for Leeds.

GB Leeds Dementia Strategy 19/103 HL presented the report and highlighted that it displayed a significant amount of work that was going on across the city in relation to dementia. The strategy provided a summary of the work and would help to pay further attention to these areas. It was iterated that there was a detailed delivery plan about how the city would address the actions.

Tim Sanders was in attendance for queries in relation to the strategy as the dementia commissioning lead for the city.

A query was raised in relation to section four of the strategy and the recognition that there was more resource required and whether the objectives

No. Agenda Item Action would meet the actions. It was recognised that there was further work to be done in relation to this and the importance of finding the support that carers require. The challenge as commissioners in identifying expertise to support staff and awareness was highlighted and it was suggested that the reintroduction of a dementia clinical lead would support this.

TR provided an example of a recent Continuing Healthcare Assessment panel he had been involved in and the identification of support needed which had highlighted the importance of ensuring carers receive the support they need.

TS highlighted the different areas in which carers can receive support, however there was a gap recognised and the challenge to consider what further skills are required.

A query was raised with regards to understanding dementia in relation to health inequalities and how this fits with our strategic objectives. The need to consider frailty and holistic support was acknowledged and both would be considered within the strategy.

The Chair summarised that the strategy had a clear statement of priorities with underpinning ambitions to action. A concern was raised from a commissioning aspect as to whether there would be an additional resource required and the need to be realistic on where to focus the intentions on the city. The Governing Body was informed that the objectives would be pulled together into a delivery plan with associated outcomes.

The Governing Body: a) considered and commended upon the draft Leeds Dementia Strategy.

GB People & OD Strategy 19/104 SA introduced the report and highlighted that the Governing Body approved the People & OD strategy in Autumn 2018. John Scott, Head of People and OD presented the report and iterated that this was an update rather than a new strategy. The work undertaken with LTHT was recognised and members acknowledged the further developments in line with ‘Shaping our Future’.

A query was raised in relation to how the activities were monitored and

reviewed and whether it would be appropriate to have support from a non- executive in relation to people and governance. TR was supportive of this SA/SSe approach and it was agreed that this would be taken forward outside of the meeting.

The report was commended and credit given to the team on the programmes of activity that had taken place to date, but recognised that there was still work to do.

It was acknowledged that the CCG was going through a change programme

No. Agenda Item Action and the importance of being honest with staff about this. A query was raised into what role the Governing Body should have in being visible throughout the change programme and it was agreed that this was an important position to consider.

The importance of partner organisations being involved in the ‘shaping our future’ change programme was highlighted and the need to ensure partners at both a local and West Yorkshire level are included. Members were informed that there had been a session at the Partnership Executive Group (PEG) and

there would be a development session at the West Yorkshire & Harrogate Joint Committee of CCGs in February 2020.

A discussion took place regarding future updates to the Governing Body and it was agreed that an interim report would be presented in May or July 2020 which would incorporate intentions from the Governing Body workshop to be held in February. The annual update of the strategy would also be presented SA/JS in November 2020.

The Governing Body: a) noted the progress made in the first fifteen months of the Strategy and Plan; b) commented on the content of this report; and c) endorsed and supported the plans described.

GB Smart Cities/Digital Technology 19/105 DR presented an overview of the smart cities work across the city and highlighted that it may require the CCG to adapt it’s commissioning to consider technology.

It was iterated that smart cities was about technology in everyday objects and the council house of the future was used an example to demonstrate what could be done within the house when taking a combined approach to improve outcomes including addressing the wider determinants of health.

Members were informed that the foundations of the smart cities work would be to ensure 100% connectivity across the city, increase digital literacy and improve the approach to combined data. Through this work, it could significantly change the way businesses operate.

A query was raised in relation to data liquidity and the timescales for being able to use combined data. It was acknowledged that there was already an open data platform that organisations could publish to, however the challenge was joining up data analysts to work with that data. Horizon scanning of data was discussed and the requirement to look to forecast planning.

Developments that had already been made were highlighted to allow people to have more control and more empowered to manage their care through digital technology.

No. Agenda Item Action

Members recognised that this was positive for healthcare going forward; however a query was raised in relation to unintended consequences relating to isolation. It was recognised that there was potential for unintended consequences, and that it was important to consider these and then undertake work on ethics.

A further query was raised in relation to professionals and members of the public embracing the digital world and the implications for both patients and clinical leads. It was recognised that there needed to be wider conversations on the clinical impact of technology and managing risks in relation to clinical governance.

The Governing Body welcomed the use of digital technology and it was recognised that there were links to the strategic ambitions in relation to wider determinants and integration. There was an agreement that there was a breadth of data that needed to understood and there was a need for a broader range of clinical champions to be embedded in this area of work. A suggestion was made that a future Governing Body workshop had a focus on this area to provide further detail and understanding.

The Governing Body: a) received an overview of the Smart Cities work across the city.

GB Committee Chair’s Summary - Primary Care Commissioning Committee 19/106 – 4 December 2019 SS presented the report and highlighted that the development of PCNs would be a key focus going forward for the Committee.

The Governing Body: a) received the report.

GB Committee Chair’s Summary – Audit Committee – 22 January 2020 19/107 SB presented the report and highlighted that the audit plan for 2019/20 had been discussed in detail at the Committee. Concerns had been raised in relation to the number of audits to be completed by the end of the financial year, and a detailed action plan had been requested by the Audit Committee. SB informed members that an interim meeting would take place in March 2020 with the internal auditors to review progress. Internal audit recommendations had also been raised due to the number of revised deadlines for recommendations. It was agreed that an update would be provided at the interim meeting on the outstanding recommendations.

Members had agreed full assurance in relation to the deep dive of Risk 3: Failure to achieve financial stability and sustainability.

The Governing Body: a) received the report.

No. Agenda Item Action GB Committee Chair’s Summary – Quality & Performance Committee – 15 19/108 January 2020 PA presented the Committee Chair’s Summary for the Quality & Performance Committee held on 15 January 2020.

In relation to the question that had been asked by the member of public at the beginning of the meeting, assurance was provided by the Chair of the Quality & Performance Committee that the issues raised were important and issues

that the CCG was aware of and the Committee received assurance of what was being actioned in relation to that.

It was agreed that the Governing Body would receive the response once it had HL been written and provided to the member of the public.

The Governing Body: a) received the report

GB Integrated Quality & Performance Report (IQPR) 19/109 HL presented the Integrated Quality & Performance Report (IQPR) and confirmed to members that this had been reviewed in detail by the Quality & Performance Committee.

Members were informed that the cancer performance targets for Leeds had considerably improved over the last couple of months. It was highlighted that due to the small numbers and variances, it was important to consider setting

the context. It was iterated that the 2 week wait target was back on track following a difficult period and virtually all cancer targets were now green.

It was iterated that the A&E performance had been good for winter and up to 90% during the last week of January.

In relation to primary care, members’ attention was brought to the figures in relation to the annual health checks for people with learning disabilities and informed that the figures for quarter 2 had improved and there had been extra investment. Members were assured that this was a key priority for the year.

The Governing Body: a) received and reviewed the IQPR dashboards, discussed the information and noted the current areas of underperformance and mitigating action.

GB Finance Report 19/110 VPS presented an update on the financial performance of NHS Leeds CCG for the nine months to 31 December 2019 and the expected outturn position for the 2019-20 financial year.

Members were informed that the CCG was on target to achieve its financial control total of £1.3bn. It was acknowledged that as the CCG enters the final

No. Agenda Item Action quarter of the financial year, the organisational financial forecasting across Leeds and West Yorkshire was more reliable. The CCG was forecasting to meet all statutory duties and to pay bills 95% of the time.

In relation to West Yorkshire, members were informed that risks highlighted had significantly reduced. In relation to QIPP and the non-achievement of the additional capacity wards scheme, a decision had been made not to close the wards over the winter months. Members were assured that LTHT were revisiting longer term demand and capacity plans, and would consider their position again in the context of the Leeds system’s future capacity and associated workforce requirements.

The Governing Body: a) noted the Month 9 financial position.

GB Ratification of Urgent Action 19/111 The Governing Body was asked to ratify an urgent decision made on 12th December 2019 in relation to a Waiting List Initiative (WLI) proposal from Leeds Community Healthcare NHS Trust (LCH) and an investment of £1,781k.

In line with the CCG Standing Orders, the urgent decision was approved by the Clinical Chair, Chief Executive, Chief Finance Officer, a Lay Member, and a Member Representative.

The Governing Body:

a) ratified the urgent decision to approve the Waiting List Initiative (WLI) proposal from LCH and an investment of £1,781k.

GB Chief Executive’s Report 19/112 TR presented the Chief Executive’s Report and highlighted the key areas within the report.

Members were informed that there would be a particular focus in the new year on IAPT performance improving as the new service model had been mobilised. NHS England would be considering whether it had the desired impact.

The update on the ‘Year of the Nurse & Midwife’ was highlighted and acknowledged the work of nurses and what was being done locally. JH informed members that the allocation of training funds for nurses would also include general practice nurses and this would be distributed via training hubs.

The Governing Body acknowledged the Communications and Engagement report as assurance that the CCG is delivering its statutory duties to ensure public involvement and consultation.

No. Agenda Item Action

The revised West Yorkshire & Harrogate Memorandum of Understanding (MOU) was presented to the Governing Body for approval. There were minimal changes and members noted that a more comprehensive review would take place in Autumn 2020. A query was raised in relation to the governance and whether there was a requirement for Audit Committees in Common, and TR agreed to feed this in to the full review of the MOU. The Governing Body formally approved the MOU.

The Chair highlighted the importance of the CCG volunteers and their role in supporting commissioning.

The Chief Executive report was commended on what had been included.

The Governing Body: a) received the Chief Executive’s report; b) approved the revised MoU and authorised the Chief Executive to sign the final version; and c) received the Communications & Engagement update as assurance that the CCG is delivering its statutory duties to ensure public involvement and consultation.

GB Review of Operational Scheme of Delegation 19/113 VPS presented the report and informed members that the Operational Scheme of Delegation had been reviewed and updated to improve the clarity and ease of use of the document. There were some proposed amendments to financial delegated limits to allow appropriate delegation to the senior leadership team.

Members were informed that the scheme of delegation would be retaining EU thresholds for at least 12 months.

The Chair of the Audit Committee confirmed that the committee had reviewed the operational scheme of delegation and recommended that it be approved.

The Governing Body: a) approved the proposed amendments to the Operational Scheme of Delegation.

GB Questions from Members of the Public 19/114 There were no questions asked from the members of the public present.

GB Forward Work Programme 2019/20 19/115 The Governing Body’s work programme was presented for information.

The Governing Body: a) received the forward work programme.

No. Agenda Item Action GB Any Other Business 19/116 IC provided an update to the Governing Body on the coronavirus, informing members that in the UK, an assessment and detection phase would be led by Public Health England (PHE). It was highlighted that the key issue would be communication and partners working together. Members were assured that the health and care system in Leeds was prepared and weekly meetings between partners were taking place.

A query was raised in relation to the channel of communications to primary care and members were informed that the guidance for primary care was clear.

The Chair highlighted that this would be Ian Cameron’s final Governing Body meeting as he would retire in February 2020. On behalf of the Governing Body and the CCG, the Chair expressed his thanks for all the expertise and knowledge and wished him a happy retirement.

IFI1. Minutes of the West Yorkshire & Harrogate Joint Committee – 5 November 2019

The Governing Body: (a) received the minutes for information.

The Governing Body resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Date of next meeting: Wednesday 27th March 2020

Approved and signed by:

Dr Gordon Sinclair, Clinical Chair, NHS Leeds CCG

Date:

MINUTES ACTION LOG – GOVERNING BODY

ITEM ACTION ACTION: ACTION BY: COMPLETED/UPDATE NO: NO: 25 September 2019 19/68 1 Approval of Procurement Plan In progress. Procurement Policy to be revised following discussion regarding risk MVT Policy update underway. To be stratification approach. presented to Audit Committee on 22 April 2020. Brought to May Governing Body. 29 January 2020 19/96 1 Questions from Members of Public HL/SRa Complete. In relation to the questions asked, it was submitted as a written Written question prepared by HL and question and agreed that a written response would be sent to the approved and signed off by Phil member of the public following the meeting. The Governing Body Ayres. would also receive a copy of the response.

19/101 1 Governing Body Assurance Framework TR/SB Complete. The Committee discussed the review of risk 6 and the timing of this Risk 6 deep dive to take place at being presented to the Audit Committee. It was agreed that TR and Audit Committee meeting on 22 April SB would discuss outside of the meeting. 2020.

19/104 1 People & OD Strategy SA/SSe Complete. Support from a non-executive in relation to people and governance SSe has agreed to provide non- was discussed and it was agreed that this would be taken forward executive support and this will be outside of the meeting. progressed through the People & OD team. 19/104 2 People & OD Strategy SA/SRa In progress. The Governing Body agreed that an interim report would be presented Added to the forward work plan. to incorporate intentions from the Governing Body workshop to be held in February. The annual update would also be presented in November 2020. SRa to add to the forward work plan.

19/118 1 Staff Survey SA/SRa Complete. Results and action plan to be presented to March 2020 Governing Added to the forward work plan. Body meeting.

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Agenda Item: GB 19/126 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting

Date of meeting: 25 March 2020

Title: Corporate Risk Register (Operational Risks)

Lead Governing Body Member: Sabrina Tick as Armstrong, Director of Organisational Category of Paper appropriate Effectiveness () Report Author: Anne Ellis Playfair, Risk Manager Decision Reviewed by EMT/Date: 19 February 2020 Discussion  Reviewed by Committee/Date: Quality and Performance Committee 11 March 2020 Information Primary Care Commissioning Committee 5 February 2020 Checked by Finance (Y/N/N/A - Date): N/A Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge  2. Failure to assure the delivery of high quality services, leading to commissioned services not  reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability  4. Lack of provider and clinical support for change will impact on the development and  implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve  health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions  7. Failure to enable partners to work together to deliver the CCG commitments  8. Failure of system to be adaptable and resilient in the event of a significant event  1

EXECUTIVE SUMMARY: The CCG uses Datix as an internal risk management system which enables operational risks to be recorded and managed by all members of staff. Risks are aligned to the appropriate CCG committee for overview and scrutiny.

The risks are included on the CCG operational risk register and reviewed within individual directorates on a regular basis. In line with the Risk Management Strategy, the Executive Management Team (EMT) and relevant CCG Committees receive and review the operational risks rated as high amber (12) and above. The CCG Governing Body receives the corporate risk register (all red operational risks scored at 15 and above) for review at each meeting, supported by the CCG committee chair updates.

Summary Table Current Previous (January 20) Total Risks 61 59 Red Risks 15+ 1 0 Amber 12+ 4 8 Accepted Risks 28 27 New Risks 5 2 Closed Risks 3 0

Accepted Risks There are currently 61 active risks on the CCG risk register, 28 of these risks are categorised as ‘Accepted’ risks. This means that the current level of risk is deemed acceptable. Accepted risks are risks that are at, or below, the target risk score (approved by the responsible Director) or are green on the risk matrix below. These risks are reviewed by management at least on an annual basis or when the CCG becomes aware of a change to the risk. High amber (12) or red risks are unlikely to be accepted and will continue to be reported to the relevant Committee and Governing Body.

Impact score Likelihood 1 2 3 4 5 Insignificant Minor Moderate Major Catastrophic 5 Almost 5 10 15 20 25 Certain 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5

Corporate Risks There has been an increase from 0 to 1 corporate (red) risk recorded on the operational risk register. The following risk with a current score of 15 has been added, this risk is aligned to the Audit Committee:

 R721 – Information Security Maturity: risk added following completion of the penetration testing.

A summary of the risk is provided below but further detail of the risk, including controls and assurances, can be seen in Appendix 1.

Risk Rating

Current Position

Risk ID Risk

Current

Risk Title Risk

Changes to to Changes

Target Date Target Date Target

Target Score Target

December October

New risk added following completion of the penetration testing. There is a cyber security risk on the operational risk

as no mitigation has been carried out for

this risk (an action plan is being 15 9 0 721 developed) and this risk includes more

than the risk of cyber-attack. This risk will 01/03/2021 be closed on completion of the action plan and R578 cyber security will remain but at Information Security Maturity Security Information a reduced score.

Risks Aligned to the Governing Body There are 13 risks aligned to the Governing Body. These relate to Finance, Procurement and the Shaping Our Future programme. Nine of these 13 risks are categorised as ‘Accepted’ risks.

Current Previous (January 20) Total Risks 13 12 Red Risks 15+ 0 0 Amber 12+ 1 0 Accepted Risks 9 9 New Risks 2 0 Closed Risks 1 0

Of the remaining four risks aligned to the Governing Body, there is currently one high amber risk. A summary of the risk is provided below but further detail of the risk, including controls and assurances, can be seen in Appendix 2.

Risk Rating

Current Position

Risk ID Risk

Current

Risk Title Risk

Changes to to Changes

Target Date Target Date Target

Target Score Target

December October

New risk added relating to the Shaping

Our Future Programme. The actions and

– due date are currently concentrated to

the development phase of the

programme and will be reviewed once

the operating model has been 12 N/A N/A 9 0

718 developed. 30/04/2020

Shaping Our Future Future Our Shaping

Stakeholder Engagement Stakeholder

NEXT STEPS:

 All operational risks will be reviewed as per the bi-monthly cycle in accordance with the CCG risk management strategy and presented to the assigned committee for review. The Corporate Risk Register and high amber risks aligned to the Governing Body will be presented to the CCG Governing Body at each meeting.

RECOMMENDATION:

The Governing Body is asked to:

(a) NOTE the changes to the Corporate Risk Register: (b) REVIEW the high scoring amber risk aligned to the Governing Body; and, for both risks; (c) CONSIDER whether the controls, actions are effective and whether assurances are sufficiently robust; and (d) AGREE any further actions required to manage the risk to the target set.

Initial Score Current Score Target Score

L L L

C C C

Risk ID Risk Description C Positive Controls & Existing Assurance in Place Gaps in Control and Assurance Actions required Status

1-5 1-5

1-25

1-25 1-25

date date

Initial Initial

Target Target

Current Current

Date last

Risk Title Risk

reviewed

Reason for

Committee

Risk Owner Risk

Target date

Initial Score

Responsible

Target Score

Current Score

Date added risk

change to target Changes to target Microsoft patching on Desktop and Servers is provided by LCC Anti-virus is installed on all desktop and server estate Engagement with LCC on Full patching NHSMail is a centrally controlled ingress Engagement with LCC on Third party patching (Ivanti) There is a risk of malicious file types gaining entry into Redcentric firewall has been installed on the internet boundary; not yet fully Upgrade affected server estate to eradicate SMBv1 the enterprise and taking hold as a result of: configured & .Net New risk added following completion - Outdated software Windows ATP(Advanced Threat Prevention) is installed on all Windows 10 devices Network (RAS) hardening activities of the penetration testing. There is a - SMBv1 Enabled Symantec Endpoint Protection (SEPP) in installed on all Windows 7 devices Assessment of Protective monitoring and cyber security risk on the operational - Poor Password Culture System Event Management installed for Solarwinds to improve monitoring position implementation of controls risk register (R578), this risk is scored - System misconfigurations Updated password protocol - communications and higher as no mitigation has been - Authentication Mechanisms testing of passwords carried out for this risk (an action 721 Resulting in: 4 5 20 3 5 15 An action plan is being developed. 3 3 9 0 N/A Windows 10 roll out and standardisation plan is being developed) and this risk

- Loss of data

30/01/2020 01/03/2021 30/01/2020 Applocker installation to reduce unmanaged includes more than the risk of cyber- - Access to data Audit Committee Audit applications on desktop and address out of support attack. This risk will be closed on - Integrity of data desktop applications completion of the action plan and - Access to network. Information Security Maturity Security Information Update configuration of desktop and server estate, R578 cyber security will remain but at In addition could result in failure of the DSPT, resulting including, but not limited to: SMB signing, denied a reduced score. in Data flows from NHSD and other organisations being

VissehPejhan-Sykes -Officer Chief Financial anonymous logons and unique community strings restricted. Segregate Active Directory from LCH Move from HTTP to HTTPs to secure internet facing services

C = Consequence (Impact) L = Likelihood

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Initial Score Current Score Target Score

L L L

C C C

Risk ID Risk Description C Positive Controls & Existing Assurance in Place Gaps in Control and Assurance Actions required Status

1-5 1-5

1-25

1-25 1-25

date date

Initial Initial

Target Target

Current Current

Date last

Risk Title Risk

reviewed

Reason for

Committee

Risk Owner Risk

Target date

Initial Score

Responsible

Target Score

Current Score

Date added risk

change to target Changes to target Updates given to PEG throughout the procurement process and following the appointment of Deloitte & AGEM, Dec 5th 19 Shadow PEG played integral part of procurement process There is a risk that there will be a perception amongst Members of LCC on Delivery Group New risk added relating to the external stakeholders that the 'shaping our future' work Deloitte&AGEM & AGEM delivery approach for Jan-March 20 includes 1:1s with PEG Session Shaping Our Future Programme. The is focussed only on the CCG and excludes key partners. members of PEG One to one provider meetings actions and due date are currently 718 This could lead to damaging the relationships with 4 4 16 Workshop with Population Outcomes Board and Deloitte & AGEM on 18/12/19 3 4 12 Further engagement to take place. Workshops 3 3 9 0 N/A concentrated to the development

partners in our place and could also mean that the SLT Stakeholder Engagement phase of the programme and will be

22/01/2020 22/01/2020 30/04/2020

Engagement project is less successful due to external stakeholders Provider Engagement reviewed once the operating model Governing Body Governing

not being adequately engaged. has been developed.

Shaping Our – Shaping Future Stakeholder Katherine DirectorSheerin, Katherine of System Integration

C = Consequence (Impact) L = Likelihood

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Agenda Item: GB 19/127 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting

Date of meeting: 25 March 2020

Title: Governing Body Assurance Framework (Strategic Risks)

Lead Governing Body Member: Sabrina Tick as Armstrong, Director of Organisational Category of Paper appropriate Effectiveness () Report Author: Anne Ellis Playfair, Risk Manager Decision

Reviewed by EMT/ Date: 04 March 2020 Discussion  Reviewed by Committee/Date: N/A Information

Checked by Finance (Y/N/N/A - Date): N/A Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

EXECUTIVE SUMMARY:

1. The Governing Body Assurance Framework (GBAF) provides a structure and process that enables the CCG to focus on the principal risks to achieving its strategic commitments and be assured that adequate controls are operating to reduce these risks to acceptable levels (the risk appetite). The risk appetite is translated into a target risk score for each risk.

2. The GBAF format enables the Governing Body to review each of the risks, analyse the controls and assurances, clearly identify any gaps and the actions needed to address them. The graph illustrates the movement of the risk score throughout the year in relation to the target risk score. The target risk score is the total impact of risk the CCG is prepared to accept in pursuit of its strategic commitments and has been agreed for each risk.

3. As part of the review cycle, each of the principal risks have been reviewed and updated by the director leads. Updates made since the previous version are highlighted in bold italics.

4. There are currently a number of risks in which the CCG is operating above the agreed risk appetite. For these risks a number of mitigating actions have been identified and once implemented, the risk level should reduce to the level of risk appetite the CCG has agreed to tolerate.

5. The GBAF risks are being reviewed for 2020/21 by the individual members of the EMT and it is planned to bring the refreshed GBAF to the EMT meeting on 1 April and the Governing Body workshop on 8 April for discussion, and for formal approval at the Governing Body meeting in May 2020. The purpose of the review is to consider: a. Whether the risks adequately reflect the risks faced by the CCG in delivering its strategic aims; and b. Whether there are any additional risks, arising from the changing environment, for example through the Shaping Our Future Programme.

6. The Risk Management Strategy includes a review of the assurances provided by the GBAF (deep dive). The deep dive is designed to provide assurance to the Audit Committee that the CCG can place reliance on the assurances provided by the GBAF. The strategy states that principal risks outside risk appetite will be reviewed in detail at least once a year to assess the adequacy and completeness of the assurances. The Governing Body receives assurance from the Audit Committee Chair in relation to the GBAF deep dive assurance paper. The Audit Committee will receive a deep dive into Risk 6, insufficient workforce capacity, capability and adaptability to deliver the ambitions (Primary Care), at its meeting on 22 April 2020.

NEXT STEPS:

The Governing Body will continue to review the GBAF at each meeting and directors will continually monitor and update their risks accordingly.

RECOMMENDATION:

The Governing Body is asked to:

(a) REVIEW the Governing Body Assurance Framework; (b) CONSIDER whether the controls and assurances are sufficiently robust; (c) AGREE any further actions required to manage the risks to the target set; (d) NOTE the review and assurance processes.

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Appendix 1 Governing Body Assurance Framework (GBAF)

Introduction

The Governing Body Assurance Framework (GBAF) sets out how the CCG will manage the principal risks to delivering the strategic commitments. The GBAF enables the Governing Body to corporately assure itself (gain confidence, based on evidence). The framework aligns principal risks with the commitments, and highlights key controls and assurances.

Where gaps are identified, or key controls and assurances are insufficient to reduce the risk of non-delivery to acceptable levels (within the CCG risk appetite), action needs to be taken. Planned actions will enable the Governing Body to monitor progress in addressing gaps or weaknesses and to ensure that resources are allocated appropriately.

Governing Body responsibility for the GBAF

It is for the Governing Body to:  Establish strategic commitments.  Identify the principal risks that threaten the achievement of these aims.  Identify and evaluate the design of key controls intended to manage these principal risks.  Set out the arrangements for obtaining assurance on the effectiveness of key controls across all areas of principal risk.  Evaluate the assurance across all areas of principal risk.  Identify positive assurances and areas where there are gaps in controls and / or assurances  Put in place plans to take corrective action where gaps have been identified in relation to principal risks.  Maintain dynamic risk management arrangements including a well-founded risk register.

Assurance

The Executive Management Team and Governing Body receive the GBAF bi-monthly. The Audit Committee annual work plan will ensure that principal risks outside risk appetite are reviewed in detail at least once a year, to assess the adequacy and completeness of the assurances, the Governing Body will receive a copy of the assurance provided to the Audit Committee.

The GBAF provides the basis for the preparation of a fair and representative Annual Governance Statement. It is the subject of annual review by both Internal and External Audit.

CCG Commitments:

We will focus our resources to: . Deliver better outcomes for people’s health and well-being . Reduce health inequalities across our city

We will work with our partners and the people of Leeds to: . Support a greater focus on the wider determinants of health . Increase their confidence to manage their own health and well-being . Achieve better integrated care for the population of Leeds . Create the conditions for health and care needs to be addressed around local neighbourhoods

CCG Risk Appetite Statement

NHS Leeds CCG recognises that the long-term health of its population depends upon the delivery of its strategic ambitions and its relationships with its service providers, staff, public and partners. As such, NHS Leeds CCG will not accept risks that have a material adverse impact on quality of healthcare, health inequalities or life expectancy.

NHS Leeds CCG has a greater appetite to take considered risks in relation to opportunities where positive gains can be anticipated such as clinical and contractual innovation, where necessary, testing the constraints of the regulatory environment.

Summary of Principal Risks

Risk Initial Current Target Key changes since last review Ref Risk to delivering the CCG commitments Appetite Score Score Score 1 Inadequate patient and public engagement results in ineffective decisions and Averse 20 4 4 No change to current score; controls and challenge actions updated; actions ongoing. 2 Failure to assure the delivery of high quality services, leading to commissioned Averse 20 8 6 No change to current score; controls updated services not reflecting best practice and improving care and actions ongoing.

3 Failure to achieve financial stability and sustainability Cautious 20 6 9 The current score has reduced below target score as the CCG has greater certainty of the financial year-end position assured by financial positions being firmed up across the Place and across West Yorkshire. The Windows for risks of unplanned material changes to income and spend positions crystallising have now started to close.

The Audit Committee received assurance through a deep dive into this risk in January 2020.

4 Lack of provider and clinical support for change will impact on the development Medium 16 9 9 No change to current score, actions ongoing. and implementation of the CCG strategy 5 Resources are not targeted effectively to areas of most need, leading to failure Averse 20 16 6 No change to current score, actions ongoing. to improve health in the poorest areas The Audit Committee received assurance through a deep dive into this risk in October 2019.

6 Insufficient workforce capacity, capability and adaptability to deliver the Medium 16 12 8 No change to current score, controls updated. ambitions (Primary Care) Actions ongoing.

Following discussion at the Governing body and further consideration by EMT, it is suggested that this risk is broadened to reflect the challenges across the wider workforce, and the impact these challenges would have on the CCG delivering its strategic aims if they are not met. This will be considered as part of the annual GBAF review process.

7 Failure to enable partners to work together to deliver the CCG commitments Open 9 9 9 No change to current score, actions updated.

8 Failure of system to be adaptable and resilient in the event of a significant Averse 20 12 8 No change to current score, actions updated. event

Risk 1: Inadequate patient and public engagement results in ineffective decisions Lead Director/risk owner: Sabrina Armstrong, Director of Organisational Effectiveness Risk Appetite: The CCG has an averse risk appetite for public engagement; this means that the CCG is not prepared to take risks in this area. Relevant commitments: All Date last review: February 2020 Risk Rating Rationale for current risk score: (consequence x likelihood) All appropriate controls are in place to plan and deliver effective patient and public involvement (PPI). Initial score: 20 Current However the consequence of these controls failing has the potential to result in challenge and ultimate 4x5 = 20 10 Score referral by Scrutiny board to judicial review. This would impact on the CCG’s reputation as well as delaying Current score: 0 any proposed changes. 4x1 = 4 Target Score Target score: Rationale for target score: 4x1 = 4 A target score of 4 reflects an averse risk appetite. It would not be possible to reduce the risk to a score lower than 4. This is due to the potential consequence of a control failure supplemented by circumstances outside our control. Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):  Volunteer panel in place (PAG): Remit to provide assurance around engagement and/or consultation plans. Action Owner Due by

Significant and major engagement/consultation plans taken to Scrutiny Board for discussion Ensure communications or engagement team Strategy and Ongoing  and approval to proceed. reps co-opted onto appropriate commissioning Commissioning steering groups to ensure the patient voice is teams  CCG has a full complement of staff in place to support engagement activity. heard.  Communications and engagement incorporated into Commissioning for Value (CfV) process. Communications and  The engagement plan template includes the Equality and Quality Impact Assessment to identify Engagement Team impact on protected characteristics and discrete communities.  Contract with Voluntary Action Leeds (VAL) to support CCG engagement work across as Further enhance our approach to engagement Communications and Ongoing and involvement activity beyond our statutory Engagement Team wide a reach as possible, and also to undertake broad asset-based engagement in duties. Our focus will be on proactive, ongoing harder to reach/engage communities. VAL is continuing to recruit to their volunteer conversations with communities and individuals Health Champions. to build a foundation of evidence that supports  CCG has a lead role in continuing to develop the citywide engagement hub which includes commissioning plans for health outcomes. engagement colleagues from provider teams. The website is currently being audited to ensure it Communications team September  CCG works closely with Healthwatch as part of the People’s Voice network. meets national mandated accessibility standards 2020  CCG community network continues to grow.  Bi-monthly communications and engagement reports published and shared  CCG undertakes regular engagement with GP patient and public groups.

Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek): Internal Assurance  Evaluation reports written and provided to commissioning teams to incorporate in their plans and influence service change.  Reports published on the CCG website and shared with members of the public who expressed an interest for further detail: ‘You said, we did’.  Regular liaison with, and attendance as appropriate at, Scrutiny Board to support commissioning colleagues.  Annual PPI review published in July 2019  Monthly VAL contract meetings and VAL KPIs reviewed quarterly. Independent Assurance  ‘Amber’ assessment rating for PPI from NHS England in 2018/19 (latest rating). Link to Risk Register:  Internal stakeholder engagement audit October / November 2018; this has been rated High 305 – Compliance with the Equality Act Public Sector Duty (6) Assurance (highest rating).  NHS Leeds CCG invited by NHS England to present examples of good practice to Amber rated CCGs at a North of England workshop on Improvement and Assessment Framework (IAF)for engagement and community involvement.

Risk 2: Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care Lead Director/risk owner: Jo Harding, Executive Director of Risk Appetite: The CCG has an averse risk appetite for service quality; this means that the CCG is not prepared to take risks in this area. Quality and Nursing Relevant commitments: All Date last review: February 2020 Risk Rating Rationale for current risk score: (consequence x likelihood) The CCG has in place quality standards, and measures quality outcomes via a range of methods and processes to assure the quality 20 of care we commission for our patients. Initial score: Current Rationale for target score: 5 x 4 = 20 10 Score A target score of 6 has been applied to this risk as the CCG aims to Current score: 0 Target minimise the likelihood and consequence of the risk occurring. This 4 x 2 = 8 Score reflects an averse risk appetite. Target score: 2 x 3 = 6 Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):  Quality Surveillance tool is being utilised across the CCG (including primary care) to monitor quality and performance of our providers enabling the CCG to identify issues and offer additional support at an early stage to ensure service improvements Action Owner Due by  Process now in place, approved by Q&P, to quality assure small providers (AQP’s) Review of new AQP quality Deputy Director September  CCG Quality Visit schedule agreed for all providers and in place for 2019/20. This includes a checklist for what will be covered. assurance process to of Nursing 2020  Commissioning for Quality and Innovation (CQUIN) framework in place to incentivise providers for quality improvement and includes contract penalties where completed and presented to performance fails the Quality and Performance  Clear national and local quality expectations and standards agreed and included in contracts Committee in September  QEIA tool developed for use across WY&H and has been adopted for use by the CCG. This tool has been incorporated in to the CCG’s Commissioning for Value toolkit to ascertain risk of commissioning/decommissioning decisions by the CCG 2020.  Contractual requirement for providers to provide regular quality performance reports on key quality, safety and experience measures  Process developed and supporting measures in place to seek assurance on and assess quality impact of provider Cost Improvement Plans  Establishment of joint city wide health and local authority care home group to support quality improvement and introduction of supporting and joint processes as outlined in the care home protocol.  Various care home network meetings in place to share intelligence across the system, including CQC, LCC, commissioning and robust processes in place to support joint suspensions as and when required  Shared database (PAC) developed enabling an ‘at a glance view’ of current status of care homes and quality/safeguarding assurance of contract information  Safeguarding Key Performance Indicators and Safeguarding Standards Framework developed to monitor performance of provider organisations in terms of both safeguarding children and adults at risk.  Safeguarding Team is cited on all safeguarding DATIX reports and Serious Incidents.  A GP Safeguarding Standards Framework has been developed to monitor annually the performance of primary care in terms of both safeguarding children and adults at risk.  Oversight of Serious Incidents via STEIS and DATIX.  Leeds CCG and LTHT to pilot new Patient Safety Incident Report Framework (PSIRF) for serious incident reporting and assurance, starting in January 2020.  New system quality group for Leeds established with representatives across health and social care, with initial focus being capturing real time patient experience  Patient Insight Group has been relaunched in October 2019, an advertised drop in session will be held in November and regular meeting commence in January 2020.  New Leeds LeDeR panel established to quality assure LeDeR reviews, share good practice and inform future commissioning plans  Extra resource in post to support MCA and DOLS in Safeguarding team and the move to new liberty protection safeguards.  New statutory requirements for Designated Doctor for Child Deaths and Named GP for Adult Safeguarding – paper to EMT in November, funding agreed and recruitment in process.  Process in place for CHC team to raise concerns regarding care quality or safeguarding concerns within the CCG and to be investigated Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek): Internal Assurance  Joint Clinical Quality Review Groups (CQRG) review key quality requirements, expectations and performance requesting remedial action plans where required using a systematic and robust methodology of review and challenge  Primary Care Quality Surveillance group monitors key quality performance information and standards of quality of primary care provision, monitoring remedial action plans where required  Director of Quality and Safety attends West Yorkshire Quality Surveillance Group (QSG) where oversight of quality across West Yorkshire is discussed  Contract Management Board receives quality update briefing from Providers identifying any key areas of concern/under performance and associated remedial actions.  Integrated Quality and Performance Report, including all pathways and primary care, is reported to the CCG Quality and Performance Committee with highlights and exceptions then reported to the Governing Body  Reporting of all providers under enhanced surveillance to the Quality and Performance Committee  Robust governance structure in place within the CCG provides assurance on the quality of services to Governing Body  Annual assurance required from providers that Cost Improvement Proposals have been assessed for impact on quality and signed off by provider medical and nursing directors 5

 Safeguarding Team review and monitor the GP Safeguarding Standards Framework on an annual basis, providing advice and support where practices are non- compliant.  Safeguarding Team attend Clinical Quality Review Groups to review and gain assurance in respect of Quarterly Key Performance Indicators and the Annual Safeguarding Standards Framework which includes Section 11 assurance regarding provider safeguarding children responsibilities.  Development of the safeguarding annual declaration for care homes  Safeguarding annual declaration for private hospitals now embedded within contracts  MCA KPI’s developed ; will be monitored through CQRG processes  Quarterly patient experience reports of the Leeds Health and Care system reported to the Quality and Performance committee and annually to the Governing Body Independent Assurance  CQC inspection programme – reports and action plans are monitored via provider quality meetings  In 2018/19, Internal audits of Individual Funding Requests and Patient Experience provided High assurance and Internal Audits of Personal Health Budgets, Safeguarding, Continuing Healthcare and Performance Reporting provided Significant assurance.  In 2019/20, Internal audits of Contract Management and the Mental Capacity Act have provided Significant assurance and of Incident Reporting provided High assurance. Additional Comments: Link to Risk Register: 28 – Learning from medication related incidents (9) 688 – Utilising patient experience data to inform commissioning decisions (6) 695 - Learning Disabilities Mortality Review Programme LeDeR (9) 707 – System Flow (12) 664 – Community Care Beds – Medicine Review (9) 334 – Amber Drug Monitoring via Neptune (8)

Risk 3: Failure to achieve financial stability and sustainability Lead Director/risk owner: Visseh Pejhan-Sykes, Chief Finance Officer Risk Appetite: Given the statutory nature of financial duties of the CCG, the CCG has a cautious risk appetite for financial efficiency; this means the CCG will accept a low level of risk in this area. Relevant commitments: We will focus our resources to - Date last review: February 2020 . Deliver better outcomes for people’s health and well-being . Reduce health inequalities across our city Rationale for current risk score: Risk Rating  Risk levels revised at the start of each financial year when risks of financial delivery for the next year are at their highest. As we (consequence x likelihood) approach the close of the financial year, financial positions are being firmed up across the Place and across West Yorkshire Initial score: and the windows for risks of unplanned material changes to income and spend positions crystallising have now started to 5 x 4 = 20 close. 20 Current . Failure to achieve financial stability could lead to a breach in our statutory duties and have an adverse effect on our local population. Current score: 10 Score NHSE is increasingly concerned about rapidly deteriorating finances in CCGs where previously healthy year end projections have 3 x 3 2 = 96 0 spiralled into deficit positions in-year, often due to a lack of scrutiny and understanding of the CCG’s underlying recurrent financial Target score: Target position under its Governance processes. 3 x 3 = 9 Score . Whilst the CCG has a number of key financial controls and financial contingencies in place to monitor and deliver financial performance in 2019/20, it’s longer term financial stability is predicated either on the delivery of a significant QIPP programme, or a significant increase in allocations to around 5%+ per annum. . The system is increasingly being assessed on financial delivery at Place level to include all NHS providers in the City. Therefore the CCG shares the risks of delivery for its NHS Providers as well. Currently the level and magnitude of CIP at LTHT alone is circa 6% of their total income of over £1.3bn. . Projections of the CCGs financial plans into the next 5 years suggest that from 2019/20 and thereafter, the CCG and Leeds as a Place is facing significant financial pressures with cost reduction schemes still to be identified, evaluated and negotiated across the system.

Rationale for target score: . Commissioners are facing significant and increasing risks from changes to NHS policy such as Transforming Care Partnerships, as well as demographic challenges at a time where annual investment in the NHS is at its lowest. Our local acute provider has significantly ageing estates stock requiring at least £350m of investments to modernise and ensure that care can be provided in the most effective configuration conducive to patient care. There are simply not enough resources available in Leeds to meet all current needs and demands. By December, most risks have either crystallised and mitigated or are no longer a risk to the system. The remaining risk score reflects the winter period and associated financial risks as well as end of year whole NHS position uncertainties. . The rationale behind the reduced risk (post assessment of risk appetite) is that Leeds does have the option to consult on rationing the provision of healthcare – a measure that is already being implemented in other areas and Leeds is also making progress on risk alignment across the health system to change clinical decisions that can improve system efficiency and reduce system costs. Allowing flexibility for increased investment towards the end of the financial year. Controls (what are we currently doing about the risk) Mitigating actions (what more should we be doing?):  Balanced Financial Plan for 2019/20 submitted to NHSE (shared with Governing Body) noting contingencies and mitigation for 2019/20 financial balance. Significant financial risks in Leeds as a Place. Action Owner Due by  Continued in depth and rigorous monthly financial reporting to budget holders, NHS England, the Governing Body and executives  Business Intelligence data now much more sophisticated for Leeds and the wider system using RAIDR and the Urgent Care Dashboard  Budgetary and governance control systems for identifying and controlling financial risks – ranked high assurance by the Internal Auditors every year  Detailed financial policies and budgetary control framework outlines responsibilities and ground rules  Commissioning for Value Delivery Board to oversee delivery of QIPP  Aligned Incentive Contract with main Acute Provider – major success stories published and year 2 agreed  Regular CFO meetings across Leeds, West Yorkshire and Y&H  Scheme of financial delegation and detailed financial policies  Monthly budget reports are issued and discussed at budget holder meetings  Budgetary control framework in place and rated high in assurance by Internal Auditors Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek) : Internal Assurance  Health and social care economy in Leeds is financially challenged and the magnitude of values involved in one of the largest “places” in  Monthly finance report to EMT, Audit Committee and Governing Body identifying any current financial risks the UK means that the challenge is of significant financial value (and potentially unmanageable) nationally and locally if the system  Prescribing finance position included in monthly finance updates spirals into deficit.  Escalation of exception reports from Commissioning for Value Delivery Board to Governing Body  Within the context of the West Yorkshire and Harrogate Integrated Care System (ICS), Leeds is also the only place that is seen to have  Procurement Programme monitoring and delivery reporting financial headroom due to it higher historic surplus retention and agreed drawdown for 2091/20 position and is therefore potentially  Lead commissioner monthly forecasts expected to shoulder the added burden of “propping up” other places by considering exceeding its control total delivery in 2019-20.  Financial impacts of primary care commissioning appear to be less significant at current stage of planning  A shared control total for West Yorkshire and Harrogate does however offer potential (if delivered in its totality) to attract significant 7

Independent Assurance transformational resources into the ICS footprint which will benefit all parties to the ICS. Much of this is outside of Leeds’ control to  Internal and external audit reports provide high assurance every year – latest is for 2018/19. deliver with the added potential burden of having to hold peers to account to ensure securing these funds in addition to “keeping our  NHSE assurance meetings have resulted in the Leadership of the CCG across all areas being rated Green own house in order”.  Internal audit of financial systems provided High assurance and QIPP provided significant assurance in  The wider Leeds Health and Social Care system is also closely interlinked with the provider landscape potentially suboptimal in its 2018/19. current configuration to deliver the most cost effective and seamless care for service users in Leeds.  Internal Audit of Budgetary control and reporting and key financial controls provided High assurance in 2019/20. Additional Comments: Risk register: The CCG has to ensure value in commissioning spend – some relates to areas of limited clinical value, others 661 – Citywide overspend against prescribing budget (9) around more effective commissioning. Some decommissioning of services will need to be considered and whilst 681 – Impact of IFRS16 ( 9 ) this will be overseen by the Commissioning for Value delivery board, Commissioning Teams have in essence been set their spending envelopes initially for 2019-20 and for the next 4 years by the autumn of 2019. Developments and changes in the mix of services commissioned to meet national targets and remain within their envelopes are therefore delegated to them as a package. However, ownership of these decisions must still clearly and visibly sit with the Governing Body via the Commissioning for Value Board. The risks associated with financial stability will potentially be reduced later in the year as risks either crystallise, disappear or are mitigated in 2019-20 for the CCCG and for Leeds as a Place. However, longer term risks still remain across Leeds and the challenge for Leeds now is to develop the NHS Estates with some potentially significant investments at the Leeds General Infirmary which will need to be affordable in recurrent revenue terms. The LTHT financial planning assumptions include some very ambitious waste reduction plans to ensure that the requisite revenue headroom is created prior to the start of the Final Business Case approval process.

The Internal Audit plan for 2019/20 includes the following audits designed to provide assurance against this risk:  QIPP

Risk 4: Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy Lead Director/risk owner: Katherine Sheerin, Director of System Integration Risk Appetite: The CCG has a medium risk appetite for the transformation of the CCG function and purpose; this means the CCG will accept a medium level of risk In this area. Relevant commitments: Date last review: February 2020 We will focus resources to - . Deliver better outcomes for people’s health and well-being . Reduce health inequalities across our city We will work with our partners and the people of Leeds to - . Achieve better integrated care for the population of Leeds Create the conditions for health and care needs to be addressed around local neighbourhoods. Rationale for current risk score: Risk Rating Likelihood - through the providers’ Committees in Common approach (Leeds Providers’ Integrated Care Collaborative - LPICC), Provider (consequence x likelihood) Partnership Board and supporting clinical strategy groups, there are strong arrangements in place to ensure strategic support and Initial score: alignment between commissioning priorities and provider development. Whilst there is a positive reception among providers the greater 4 x 4 = 16 20 engagement of clinicians and working through of the necessary detail still needs to take place. Current score: Current 10 3 x 3 = 9 Score Consequence - the failure to gain support of all major providers will significantly limit a number of key objectives of the strategy in 0 Target score: Target particular greater integration. 3 x 3 = 9 Score Rationale for target score: Whilst the support of providers is key to delivering the changes articulated in the CCG strategic plan, it is unlikely that we will have full support of all clinicians for all the changes we need to make. There will be trade-offs to be made as we place more emphasis on prevention, early identification, proactive care and treatment of people closer to home, and the risks of these trade-offs need to be understood and managed whilst not detracting us from the strategic aims.

In addition, the move in Leeds from an individual organisational focus to system focus means that the development and implementation of the CCG strategy is equally dependent on the alignment of the CCG’s commissioning approach with the Local Authority. Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):

 Leaders of main provider organisations come together with commissioning and care leaders across the city as the Partnership Executive Group. This aims to ensure coherence of strategy and approach across the city, and delivery of Action Owner Due by the goals set out in the Health and Wellbeing Strategy. Development of agreed clinical model (based on population Katherine Apr 2020  The Clinical Senate (co-chaired by the CCG Medical Director) meets on a bi-monthly basis to bring clinical leaders health analysis) for the city. This is now known as the ‘left Sheerin July 2020 together. shift blue print’ and will involve clinicians across the system. rd  A Committees in Common is in place across all 4 NHS providers, with the Local Authority (provider) and 3 sector representation. There is a work plan (aligned to the CCG Strategic Plan) with some clinically led work to re-design Given the significance of this work, and the need to services across organisations, for example Frailty. ensure alignment with Building the Leeds Way, it is  There are other examples of clinically led work supported by the CCG, for example in Long Term Conditions. suggested that the deadline is extended until July 2020.  The CCG System Integration Team supports much of this work, with a director level joint appointment (Director of System Integration) and senior expertise.  The CCG is actively supporting the development of PCNs and LCPs, and has participated in a 20 week intensive population health management programme. This clinically led approach to service improvement will now be rolled out across the city.  A second phase to introduce PHM at local level has commenced with a further 8 LCPs participating.  Project team established to produce the ‘left shift blue print’. This will be led by the CCG, co-produced with partners. Clinical leaders to be engaged via Heads of Commissioning. Final plan to be agreed by the system.  Co-production of Aligned Incentive Contract with LTHT reflects provider support to new approaches to contracting as part of wider commissioning strategy.  We have supported the development of the GP Confederation to ensure the voice of primary care as a provider is clear in strategic discussions, and to identify and delivery economies of scale in order to maximise clinical time where appropriate.  The Clinical Commissioning Forum in January 2020 is being used to bring together PCN Clinical Directors with CCG Clinical Leads, CCG and Confederation officers to explore how the CCG supports and works with the emerging PCNs to take on a more strategic and integrated role in delivering healthcare and improving outcomes for patients in the context of the ‘Shaping Our Future’ programme.

Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek) : Internal Assurance  Providers collectively choose to prioritise and focus on work that supports delivery of CCG Strategic Plan e.g. working  Internal measures and milestones to measure the assurances described. collectively to deliver system outcomes  Increasing levels of trust between leaders of commissioning and provider organisations in Leeds. Commissioning and Provider leaders proactively engage with each other to inform decision making that will have a system impact.  Clinical and financial risks are shared and managed differently between the CCG and providers and also between providers, with resources shifting to enable improved health outcomes and inequalities to be addressed.  The Provider CIC (LPICC) work-plan aligning with the CCG Strategic Plan and Delivery Framework priorities.  PCNs starting to operate successfully, offering services beyond the contract.

Independent Assurance  360 survey Additional Comments: Risk register: Very good progress on reducing the risk with considerable controls in place. Still require a period of time to ensure new 655 – Member Engagement (9) arrangements are being fully embedded and that system relationships strengthen further before risk within risk appetite. 707 – System flow (12)

The Internal Audit plan for 2019/20 includes the following audit designed to provide assurance against this risk:  Development and Delivery of the Commissioning Strategy and Plan – deferral of this audit to Summer 2020 has been approved by the Audit Committee.

Risk 5: Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas Lead Director/risk owner: Katherine Sheerin, Director of System Integration Risk Appetite: The CCG has an averse risk appetite for health inequalities; this means that the CCG is not prepared to take risks in this area. Relevant commitments: Date last review: February 2020 We will focus resources to - . Deliver better outcomes for people’s health and well-being . Reduce health inequalities across our city

Rationale for current risk score: Risk Rating Commissioned services and programmes may not be designed in a way which meets the needs of groups who have (consequence x likelihood) poorer access to services, particularly preventive, proactive and primary care services. This could result in an increase Initial score: in health inequalities with some patients receiving sub-optimal care and potentially poor patient experience outcomes. 4 x 5 = 20 20 Current score: Current Most recent Public Health Annual Report has identified increased inequalities across the city, with more people living in 10 Score 4 x 4 = 16 0 the 10% most deprived wards. Target score: Target 3 x 2 = 6 Score Rationale for target score: The CCG has a legal duty to reduce inequalities in the population in terms of both access to services and health outcomes. This is a key strategic aim the CCG’s Strategic Plan in line with the Health and Wellbeing ambition that the Leeds will be a healthy and caring city for all ages, where people who are the poorest improve their health the fastest. This is a significant challenge, particularly given reductions in funding across the public sector and the changing nature of the communities we serve. And it is recognised that inequalities in the city have actually widened over the past decade. As such, we need to work with partners to endeavour to make the difference, and to ensure that CCG resources are targeted to best effect.

Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):

 CCG Strategic plan is grounded in the Health and Wellbeing Strategy and reflects the city Joint Action Owner Due by Strategic Needs Assessment (JSNA) & local health needs with a clear focus on reducing health Develop clear approach for CCG to take to address health Katherine Sheerin March 2020 inequalities. inequalities, signed off by the Governing Body and supported by  CCG is an active member of the Health and Wellbeing Board and other partnership partners. Workshop held in December 2019 – investment arrangements, e.g. Partnership Executive Group, Leeds Health and Care Plan principles debated. Output from the workshop to be built into  CCG Health Inequalities Framework – the CCG Governing Body has recently endorsed an revised Health Inequalities framework, with formal sign off by Interim Health Inequalities Framework for Action. This describes how the CCG will use its Governing Body planned for March 2020 (revised dates agreed £1.3bn resource to drive the changes needed to realise the aim of reducing health inequalities. by Governing Body at workshop). It is also sets out how the CCG will use its position as a major statutory body to influence the wider determinants of health and our partners in ways which more positively impact on the Once agreed, performance framework for priorities contained John Tatton March 2020 inequalities faced by the poorest people in the city. with the Health Inequalities Framework to be developed.  Action at programme / project level – there is already significant work underway which is targeted at reducing health inequalities, including - Redesign approach to health inequalities impact assessment Becky Barwick March 2020 . Services for marginalised groups including sex workers, homeless people, gypsies and travellers, ex-offenders, etc. . ‘Equalised’ weighted funding for General Practice and greater focus on health Develop process for differential investments across the city to Becky Barwick / Matt March 2020 inequalities more effectively meet needs Turner . New IAPT service has targets built in which direct the providers to ensure Refresh the Public Health Memorandum of Understanding John Tatton January 2020 effective access for people from BAME communities and people living in deprived between the CCG and the LA to ensure appropriate support for Leeds intelligence on actions to address health inequalities. . Community midwifery teams aligned to areas of greater deprivation, working closely with children centres and health visiting teams . Long Term Plan response – the CCG is currently confirming its response to the Long Term Plan. This will require delivery of key initiatives and targets, many of which will then impact on health inequalities. In addition to schemes which are required of all parts of England, there are significant resources for schemes which are more targeted in terms of needs (for example health of homeless people) and resources to test pilot schemes. The CCG is ensuring that it is well placed to access these resources where appropriate.

 Memorandum of Understanding in place between Leeds CCGs and Leeds City Council to deliver Public Health Healthcare Advisory Service (PHHCAS) with action plan.  CCG commitment to Population Health Management approach will enable providers to work together at very local levels (through LCPs) to shape services around needs.  Commissioning for value programme now established to understand how commissioning investments impact on finance, quality and health outcomes.).  Joint data analysis team in place across Local Authority and CCG. Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek) : - Update Oct 2019 Internal Assurance The CCG does not have a comprehensive report which draws together progress in addressing health As part of finalising the Health Inequalities Framework for Action, performance measures will need to be developed. inequalities. However, there are some indicators in the current IQPR, Primary Care IQPR and General These will be driven by the priority areas confirmed by the Governing Body, and will need to provide the CCG with clear Practice Quality Improvement Scheme. information on whether resources are being targeted effectively.

External Assurances There are a number of external reporting mechanisms which will be used to build the CCG’s reporting framework, including:- Public Health England Local Authority Health Profiles Public Health Annual Report Local Authority Quarterly Report

Independent Assurance: Internal audits of Business Case Procedures and Performance Management during 2018/19 provided Significant assurance. Additional Comments: Risk register: 305 – Compliance with the Equality Act 2010 Public Sector Equality Duty (6) 688 – Utilising patient experience data to inform commissioning decisions (6) 695 – Learning Disabilities Mortality Review Programme (LeDeR) (9)

Risk 6: Insufficient primary care workforce capacity, capability and adaptability to deliver the ambitions Lead Director/risk owner: Katherine Sheerin, Director of System Risk Appetite: The CCG has a medium risk appetite for the transformation of the CCG function and purpose; this means the CCG will accept a medium Integration level of risk In this area. Relevant commitments: Date last review: February 2020 We will work with our partners and the people of Leeds to - . Achieve better integrated care for the population of Leeds . Create the conditions for health and care needs to be addressed around local neighbourhoods. Risk Rating Rationale for current risk score: (consequence x likelihood) 20 Current Despite the actions taken, the availability of a current and future workforce supply within primary care remains a national issue. Initial score: 10 Score 4 x 4 = 16 0 Rationale for target score: Current score: Target This reflects that there is a requirement to significantly increase the primary care workforce within 5 nationally mandated roles. At 4 x 3 = 12 Score this point it is likely that Primary Care Networks will be unable to recruit to 100% of the required additional capacity within the Target score: national timescales. 4 x 2 = 8 Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):

Governance  City wide approach to strategic workforce development has recently been refreshed and agreed, with 7 priorities. Action Owner Due by  City-wide Board being renewed; CCG Executive Nurse to be a member, with remit to ensure CCG commissioning priorities are reflected in Consider the challenge and opportunity Katherine 2019/20 workforce developments. set out in the NHS Long Term Plan and Sheerin  Health and Social Care Academy (funded by all partners in the city) established to deliver this programme of work. 19/20 planning guidance, including  Primary care workforce sub-group in place – TOR and membership has been reviewed to ensure alignment with PCN workforce challenges aligning potential additional investment. and links to the wider system.  The role of the Leeds GP Confederation in relation to workforce planning and workforce development is reflected in the CCG/Confederation Support Primary Care Networks in Katherine Partnership Agreement. A formal workforce subcommittee of the Confederation Board has been established chaired by the shared (with LCH) understanding their responsibilities for Sheerin Workforce Director. the 5 national mandated roles in primary  The CCG actively participates in the West Yorkshire and Harrogate ICS Primary and Community Care Workforce Group care and the funding streams associated Planning as 4 of the roles are funded at 70% cost  Primary Care Workforce action plan in place. only.  Baseline assessment of current gaps in workforce undertaken (Dec 2018).  Workforce action plans being developed at PCN level.  PCN workforce data packs have been produced and shared with PCNs to enable workforce planning.  General Practice Nurse Strategy developed and launched. Delivery  Locality leadership teams are in place across 18 agreed LCP footprints, supported by the investment to release the leaders from clinical practice with good alignment to PCNs.  The investment to support leadership has been made recurrent via the new GP contract linked to the development of PCNs.  Investment linked to workforce planning and workforce development into general practice has been made through the Quality Improvement Scheme (QIS); national initiatives e.g. Time to Care; GP Access Fund; and transformation monies.  The primary care development team has restructured and aligned to 18 LCP footprints and are actively supporting locality leaders.  New roles developing within general practice e.g. care navigation; Rotational Paramedic; role of occupational therapists in primary care pilot; shared roles across a number of practices. The new GP contract sets out 5 mandated roles and the funding to support them over the next 5 years through a national directed enhanced scheme.  PCN DES workforce in year 1 focussed on additional clinical pharmacists and social prescribing link worker – 15.5wte social prescribers and 18.75wte pharmacists appointed to date.  Generation X scheme launched (initiative between Leeds LMC/ GP Confederation and CCG) to support retention of mid-career GPs.  Practice Nurse Preceptorship programme in place – successfully recruiting new PNs into the workforce.  The Confederation has developed an offer to primary care networks that includes options in recruiting and employing the additional roles described in the GP contract.  Implementation and reporting against GP Forward View (GPFV) workforce trajectories.  The CCG is leading a programme of international GP recruitment on behalf of the ICS.  Work is commencing to set out what we want to commission from General Practice from 2021, the standards patients should expect and the investment required to deliver. This is likely to incorporate the QIS and other incentives schemes, and describe what should be available at every practice, every PCN and city-wide levels. 13

Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek):

Internal Assurance Primary Care workforce: Local Care Partnerships and Primary Care Networks: Independent assurance – consider requesting a  Monitoring of the completion of workforce tool  Evidence of wider partners coming together in LCP meetings across the city. review by Internal Audit  Reporting against GPFV trajectories to NHS England  General Practice locality leaders describing their involvement with wider partners in  Primary Care Workforce Steering Group meets bi- LCPs at the Leeds GP Confederation Strategic Board. monthly chaired by CEO of GP Confederation with  Strategic support for the LCP vision evident from PEG. membership from all stakeholders  System wide stakeholder group meets bi-monthly to track progress  A report provided to the January 2019 CCG Primary  LCP development programme reported via LPICC Care Commissioning Committee which set out the  New GP contract and process to sign up the Network DES work programme for the Primary Care Workforce group and how it links into programmes at West Yorkshire and Harrogate ICS and Leeds health and Care Plan workforce structures ensuring priorities are aligned.

Additional Comments Risk register: Ensuring we have the workforce to deliver a sustainable primary care today and a workforce to deliver a transformed primary care for tomorrow is hugely complex. The 651 – General Practice Workforce (12) CCG needs to ensure that this is being addressed at city-wide levels within the context of workforce challenges across the system. 672 – Delivery of Online Consultations (9) The establishment of the Leeds GP Confederation brings new opportunity to engage with primary care ‘at scale’ and develop workforce initiatives for general practice across the city e.g. a local ‘bank’ for locum GPs; employment contracts that allow working across a locality; development and support programmes for newly qualified GPs. This is yet to be realised. Developing Local Care Partnerships as the way of delivering integrated local services as described in the Leeds Health and Care Plan is a massive transformational programme for the whole system.

Risk 7: Failure to enable partners to work together to deliver the CCG commitments Lead Director/risk owner: Tim Ryley, Chief Executive Risk Appetite: The CCG has an open risk appetite for partnership working; this means the CCG is willing to consider a higher level of risk in this area. Relevant commitments: All Date last review: February 2020

Risk Rating Rationale for current risk score: (consequence x likelihood) 20 Changing Governance arrangements across the health and social care economy both within Leeds and West Initial score: Yorkshire may lead to failure to coordinate actions around shared priorities which could lead to omission or 10 Current 3 x 3 = 9 Score duplication of actions. Recent national guidance on the role of CCGs within the ICS will lead to a need to further Current score: 0 consider joint commissioning arrangements at West Yorkshire and Harrogate. Similarly the CCGs further 3 x 3 = 9 Target development of NHS plans and as an organisation including a review of its role within the system may cause Target score: Score some testing of Leeds systems. There remain risks around competing priorities between need for placed based 3 x 3 = 9 services and support to local providers, and the requirement to work at Integrated Care System (ICS)/ West Yorkshire Sustainability and Transformation Partnership (STP) level. Therefore risk has been increased to target level.

Rationale for target score: The appetite for this type of risk is open; a target score of 9 has allowed the CCG to take greater risk than it is currently taking, should an opportunity arise to progress / develop partnership working.

Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?):

 Integrated Commissioning Executive (ICE) meetings and Partnership Executive Group meet Action Owner Due by on a monthly basis and an Integrated Commissioning Framework is in place. Executive Team put in place stakeholder management plan around NHS Tim Complete  A new provider Committee in Common meets quarterly with representation from the Local planning and Organisational Transformation and actively manage. Ryley Authority and 3rd sector. Memorandum of Understanding (MOU) for West Yorkshire signed CCG Executive Team have agreed stakeholder management plan and in place. Ensure CCG Governing Body are kept fully sighted on emerging West Yorkshire Tim Complete  Aligned incentives contract in place across providers which facilitates alignment of priorities. and Harrogate proposals. Ryley  Representatives from the GP Confederation attend the Leeds Health and Care Partnership WYH CCG Joint Committee are reviewing progress on emerging WYH Executive Board. Representation from the Local Authority invited to the planning meeting in commissioning proposals – CCG CEO provides updates to the Governing the CCG. Body via the CEO report.  Partnership framework developed. CCG to support a Leeds system governance review on the back of Internal Audit Tim November to  CCG Executive Team stakeholder management plan. work and outputs of Leeds plan and keep Governing Body sighted. Ryley January 2020 Update to be included in CEO report to Governing Body in March 2020. April 2020  WYH CCG Joint Committee reviews progress on emerging WYH commissioning proposals – CCG CEO provides updates to the Governing Body via the CEO report. Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek) : Internal Assurance

West Yorkshire minutes and issues are included in the CEO report to the Governing Body, Integrated Commissioning Executive (ICE), Provider Committee in Common and Leeds Health and Care Partnership Executive Board. Issues are reported via the CEO to the Governing Body. The Health and Well Being Board reviews our collective progress every quarter.

Independent Assurance The Internal Audit plan for 2019/20 includes the following audits designed to provide assurance against this risk:  Partnership Governance – final report provides Significant assurance  Partnerships – advisory report

Additional Comments: Risk register: N/A N/A

Risk 8: Failure of system to be adaptable and resilient in the event of a significant event. Lead Director/risk owner: Helen Lewis, Interim Director of Operational Delivery Risk Appetite: The CCG has an averse risk appetite for service quality and performance; this means that the CCG is not prepared to take risks in this area. Relevant commitments: All Date last review: February 2020 Risk Rating Rationale for current risk score: (consequence x likelihood) 20 This risk relates to the CCG working with partners to mitigate the impact and to support recovery of the delivery of Initial score: healthcare services to the Leeds population as a result of a significant event. A significant event can be a ‘rising 10 Current 5 x 4 = 20 Score tide’ or a one off event e.g. epidemic, adverse weather therefore the mitigations and plans are wide ranging Current score: 0 across all organisations across the Leeds Health and Care system. Our current score with regards to a 3 x 4 = 12 Target significant one off event remains high due to national threat levels being severe (government). Target score: Score 2 x 4 = 8 Rationale for target score: The target score has been increased from 6 to 8, the CCG aims to minimise the impact of a significant event on healthcare services but has limited influence on the likelihood of the risk occurring and the likelihood score has been aligned with the national threat level. No system can plan for every eventuality, so residual risk will remain. This reflects an averse risk appetite in relation to impact.

Controls (what are we currently doing about the risk?): Mitigating actions (what more should we be doing?): CCG Controls

 Engagement at West Yorkshire level with local resilience forum and West Yorkshire urgent care meetings Action Owner Due by  Training for key senior managers JESIP Training, On call training EU Exit preparedness: Steering group, self-assessment, Debra Taylor Complete  Counter Terrorism and Organisational Security Awareness delivered to all staff action plan, and liaison across system and with NHS as Tate  CCG Business Continuity Plan directed  CCG Incident Response Plan with Action Cards  On call systems in all providers plus the CCG, linking to NHS England (NHSE) and region EU Exit agreed. Steering group no longer meeting but at times of pressure remains in place and able to stand up as required as  EPRR Compliance and Action Plan the negotiations in 2020 progress.  Winter plans in place, includes primary care and public health / Comms actions Implement the EPRR Action Plan Debra Taylor Mar 2020 System Controls Tate  System wide Surge and escalation plans in place and tested through exercises, In progress. There were four actions within the CCG  Business continuity plans in place for providers as part of NHS contract, including General EPRR action plan, and the current position is : practices. 1&2) Current Covid-19 planning and preparedness will  Emergency Preparedness Resilience and Response (EPRR) Compliance and Action Plan inform and form the basis for CCG Outbreak and for NHS organisations Pandemic plans.  Operational delivery meetings at LTHT and weekly Operational Winter Group 3) The Comms and Engagement team have  Leeds resilience plan and Forums in place progressed incident Comms preparation within the  Leeds Safety Advisory Group (SAG) to discuss the Health and Safety issues relating to an CCG. The extranet is updated, and information has been included on staff bulletins. An aide memoir for event and offer professional guidance staff is currently in the design stage.  System Resilience Assurance Board 4) EU Exit Planning and Business Continuity  System and regional meetings. Local Health Resilience Partnership (LHRP). Health and development have tested and informed IG Social Care Resilience Group. considerations at a time of incident, and this  Health Protection Board continues.  EPRR framework for NHS organisations includes clear roles and responsibilities for system On-call training (aligned to NHS England reporting Debra Taylor Complete wide response requirement) – ongoing following on call list review Tate  Clear roles and responsibilities for outbreak planning (NHSE, CCG. LA)  Leeds Outbreak Plan and Outbreak Roles and Responsibilities. Delivered to all existing CCG On Call managers in October/November 2019. Assurances (how do we know if the things we are doing are having an impact?): Gaps in assurances (what additional assurances should we seek) : Internal Assurance  Assurance from providers on EPRR compliance, and business continuity plans.  Leeds resilience plan has agreed x12 performance indictors to demonstrate impact from transformation activity.

 Regular testing of the CCG Business Continuity Plan  Annual self-assessment against EPRR – goes to Governing Body  Outputs from real or tested scenarios and learning – reports and action plans produced e.g. winter reviews. Independent Assurance  NHSE complete an annual CCG assurance assessment through quarterly reviews. Additional Comments: Risk register: The Internal Audit plan for 2019/20 includes the following audit designed to provide assurance 650 – CCG Business Continuity (6) against this risk: Emergency planning and Business Continuity Arrangements 706 – Emergency Preparedness Resilience and Response (8)

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Agenda Item: GB 19/128 FOI Exempt: N

NHS Leeds CCG Governing Body

Date of meeting: 25th March 2020

Title: Operational and Financial Plan 2020/21 Lead Governing Body Member: Sabrina Tick as Armstrong, Director of Organisational Category of Paper appropriate Effectiveness, Visseh Pejhan-Sykes, Chief () Finance Officer Report Author: Rob Goodyear, Head of Strategic Planning / Judith Williams, Head of Corporate Decision  Reporting & Strategic Financial Planning Reviewed by EMT/Date: N/A Discussion Reviewed by Committee/Date: N/A Information Checked by Finance (Y/N/N/A - Date): Y Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

NHS Leeds CCG Strategic Commitments We will focus resources to: 1. Deliver better outcomes for people’s health and wellbeing  2. Reduce health inequalities across our city  We will work with our partners and the people of Leeds to: 3. Support a greater focus on the wider determinants of health  4. Increase their confidence to manage their own health and wellbeing  5. Achieve better integrated care for the population of Leeds  6. Create the conditions for health and care needs to be addressed around local  neighbourhoods Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability  4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions  7. Failure to enable partners to work together to deliver the CCG commitments  8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY: The NHS Long Term Plan, published in January 2019, set out the transformation of services and outcomes the NHS will deliver by 2023/24. From this a local system-wide five year strategic plan was developed.

The NHS Operational Planning and Contracting Guidance for 2020/21 was issued by NHS England/Improvement (NHS E/I) at the end of January 2020. This paper presents the Governing Body with an update on the guidance, the work undertaken so far and the submission process moving forward.

The guidance states that operational plans are to implement the first year of local strategic plans. The ask is that system leaders agree individual commissioner and provider plans to ensure they are consistent with the goals, assumptions and financial trajectories in system plans that have been agreed with NHS England and NHS Improvement.

Systems submit a short operational narrative to set out any operational risks or variation from their agreed strategic plan and describe the action that system partners will take to manage this during 2020/21.

Systems also set out proposals to use revenue transformation or capital funds where these have been allocated to systems and the benefit they anticipate from the application of those resources.

NHS and Local Authority partners agree the key elements of the planning for the Better Care Fund and assumptions for increasing health and social care capacity.

Plans are to include how organisations, place and system will deliver a number of key targets in the following areas:  Primary care and community health services  Mental health  Learning disabilities and autism  Urgent and emergency care  Referral to treatment times (RTT)  Outpatient transformation  Cancer  Public health and prevention

The guidance also focuses on workforce and financial planning and contracting.

First draft operational plans for finance, activity, performance and trajectories, and primary care workforce have been submitted in line with national deadlines on 5 March 2020. The submission has mainly been based on completing templates, however, a place-based narrative has also been submitted to the West Yorkshire and Harrogate Integrated Care System (ICS).

This paper provides an overview of the work already completed on these plans, next steps and sign off process. Prior to NHS England’s announcement on 17 March 2020, in which they confirmed the suspension of the operational planning process for 2020/21 due to the Coronavirus situation and changing priorities for the NHS, the final submission was due on 29 April 2020. We await further details of the revised submission dates and requirements and will adjust our own sign-off timetable accordingly in due course. Proposed dates within this paper are subject to change due to this announcement.

NEXT STEPS: Further work will continue in due course on the detail on all aspects of the planning requirement – financial, activity, performance and trajectories and workforce.

It is anticipated that the ICS will provide feedback on the draft submission and further assurance meetings will be held, which will be attended by representatives of the main Leeds partners. These were originally planned for April, but again have been deferred due to the current change in priorities.

In the event of the revised final submission date restricting our ability to present the final plan to Governing Body for prior approval we are requesting that approval of the final submission is delegated to the CCG Accountable Officer and Chief Finance Officer. A further paper, outlining the final submission, will be brought to the Governing Body in due course.

RECOMMENDATION:

The Governing Body is asked to:

(a) NOTE and COMMENT on the draft plan; (b) DELEGATE authority to the CCG Accountable Officer and Chief Finance Officer to approve the final submission and associated detailed budgets, in the event of this action being required.

1. BACKGROUND

Planning and contracting guidance The Operational Planning and Contracting guidance was issued on 31 January 2020 with a deadline for draft submission by 5 March. This was three weeks later than anticipated – partly due to the national consultation with GPs on the PCN specification consultation. The full guidance and its eight appendices can be accessed via the following web address (https://www.england.nhs.uk/operational-planning-and-contracting/).

1.1 Integrated Care System (ICS) responsibilities and process The ICS is responsible for leading the system response to the planning guidance and, prior to the guidance being issued, a system planning workshop was held, and a place-based assurance meeting was held on 30 January 2020.

Since the issuing of the guidance there has been further discussion on aligning the 18 ICS Programmes with each place, and a further stocktake on progress.

In line with the planning guidance, the ICS is required to produce a system narrative, including exception reporting from each place. The ICS chose to supplement the national requirement from place with additional information. The place narrative will be key highlights which reflect all that will be delivered in 2020/21 towards achieving the ambitions within the NHS Five Year Plan.

1.2 The Leeds approach Work to understand how Leeds would deliver the ambitions within the Long Term Plan (LTP) was already being progressed following the release of the Long Term Plan’s Implementation Framework in September 2019. The government’s announcement of funding for the building of a new hospital at Leeds Teaching Hospitals NHS Trust, the Building the Leeds Way project, brought forward the timetable for this. Work on understanding how we would deliver the LTP ambitions together with Building the Leeds Way has seen the development of the Left Shift Blue Print. The ambition of the project is to agree the ‘left-shift’ ambitions for the improvement in the quality of care and in health outcomes over the next five years and to describe the service changes which are required to deliver them. One of the key stakeholders within this piece of work has been the Leeds Place Based Planners Group – the group that traditionally meets only to deliver the requirements of NHS England planning guidance.

As well as working on the Left Shift Blue Print, the Leeds Place Based Planners group has met on a weekly basis since January to ensure that we can deliver the requirements of the planning guidance. The group has coordinated responses to the usual activity, finance and performance templates as well as workforce, contracts and the additional ask of contributing to the ICS’ system narrative.

1.3 The guidance has extended the number of planning measures to a total of 74 for 2020/21. This includes 22 new indicators and one amended one. These new indicators cover:  Cancer Faster Diagnostic standard  Four additional first outpatient measures  Six diagnostic measures

 Reducing length of stay measure  Primary Care GP appointments  Eight mental health measures including two around IAPT, and one around perinatal mental health  Inpatient care for people with a learning disability or autism

The full set of planning measures can be found at https://www.england.nhs.uk/publication/nhs-operational-planning-and-contracting-guidance- 2020-21-annex-f-activity-and-performance/.

2. OUR RESPONSES TO THE PLANNING GUIDANCE

2.1 OVERVIEW OF ACTIVITY PLANS – BY EXCEPTION

The draft activity plans submitted focus on the information provided for the first year of the five year plan. However, since the five year plan was written, there have been a number of changes we are required to highlight. These are as follows:

 Referral demand for GP referrals. We have seen a 0.8% increase in 2019/20. We have allowed for a 1.5% growth in 2020/21. The largest increase in referrals is in 2 week wait pathways, particularly in colorectal, gynecology and in dermatology where we have implemented tele-dermatology.

 Referral demand for non GP referrals to General and Acute (G&A) specialties. We have seen a 4.7% growth in 2019/20. Significant increases in referral demand have been evidenced in gastroenterology and urology, which are associated with demographic growth of disease later in life and public awareness campaigns for cancer which have increased general demand. We have allowed for a further 1.5% growth in 2020/21.

 Total consultant first outpatient attendances. We have allowed for a 3.5% growth in 2020/21. The main growth areas will be in colorectal and urology to maintain 2 week wait performance.

 Total consultant led follow-ups. We have allowed for a 3.5% growth in 2020/21. The main growth areas will be in vascular, colorectal, urology and spines and in ophthalmology.

 Day cases. We have allowed a 1.5% growth in 2020/21. The increases are due to an increase in the proportion of elective surgery undertaken as day case (shifts from inpatients).

 Inpatients (ordinary). We have allowed a 1.5% growth in 2020/21. The increase is required to maintain the current admitted waiting list whilst managing an increased rate of conversion from additional non-admitted activity. This growth will support specialties where there has been staffing gaps in 2018/19 that have now been addressed (vascular) and

areas such as spines, colorectal and urology where there are backlogs and/or demand linked to increased cancer referrals.

2.2 OVERVIEW OF ACTIVITY CHALLENGES AND ASSOCIATED PERFORMANCE TRAJECTORIES

We have highlighted a number of challenging areas in our draft submission. These are areas where we are currently underperforming as a place and, for a variety of reasons, may find it difficult to meet the required targets and trajectories in 2020/21.

The following areas have been highlighted as challenges for Leeds. We will continue to work with our partners across Leeds to look at ways of increasing our performance in these areas.

MEASURE TARGET 2020/21 COMMENTARY PLAN Acute Referral to 92% 91% CCG performance has been around 87% for Treatment most of the year, with 6,000 patients currently (RTT) waiting over 18 weeks. LTHT is planning to get to Incomplete 89% by the end of March 2021 (a reduction of Pathway: 1,000 patients), with total waiting list size maintained by end of January 2021. Performance will in part depend on the ability of Harrogate and District NHS Foundation Trust on long waiters, which we are currently working on with them. Diagnostic 99% 99% We are planning to achieve the target for this test waiting measure despite further 1.5% growth in times diagnostic tests at minimum, linked to cancer demand and overall demographic growth. There is a risk in relation to the planned replacement of a CT and MRI scanner in 2020/21; plans are being put in place to mitigate against this risk. Bed 92% not During the five-week period between 30 occupancy currently December 2019 to 03 February 2020 LTHT expecting capacity was 1684 beds (including 156 beds to achieve which are considered additional capacity) and target average occupancy was 97%. To achieve 92% during this period, it would require opening around 100 additional beds. This is not feasible based on current estate and staff capacity. Therefore, the Trust is continuing to work with system partners to deliver alternative mitigations to reduce occupancy e.g. Applied Research Collaboration programme, admission avoidance, reducing the number of medically optimised for discharge patients, increasing outflow from the hospital.

We will not know the financial impact until we have completed the demand and capacity modelling work across LTHT over the next five years in line with Building the Leeds Way and the CCG’s Left Shift Blue Print work in the Spring. Mental Health Roll-out 25% 22% by Evidence indicates that Leeds IAPT access (access) end of performance has been hampered by staff 2020/21; capacity to screen referrals and screening 25% by efficiency and Physical Wellbeing Practitioner end of (PWP) recruitment and retention is a national 2021/22 issue. Actions to address this have included recruiting above capacity, and eight trainee PWPs are due to complete their training in March which will improve service capacity. However the Leeds staffing position remains challenging; with the service constantly out to recruitment for step 2 staff. IAPT Waiting 75% 55% Due to indicator design and with more than half Times - 6 of people accessing the service for at least nine Weeks months, this measure predominantly represents the waiting times of people accessing the service in excess of nine months prior to the reporting period. Therefore, performance in 2020/21 will largely represent the performance of the old service which had capacity issues. The target is 75% and consequently, we do not expect performance to improve beyond levels currently reported by NHSE until approximately Q4 of 2020/21 from which point we should begin to see the improvements being delivered by the new service in national reporting. We are looking to achieve 55% by Q4 of 2020/21. IAPT in- Max 45% by Wait times in Leeds IAPT have been longer than treatment 10% end of 90 days between first and second treatment pathway 2021 appointment for a higher % of people than 10%, waits due to historical legacies for managing waiting times capacity within the service. Plans to address this have been agreed as part of the implementation of the new service model, which have included allocation of dedicated additional staff capacity to address legacy waits. Progress against this will be monitored jointly by providers and commissioners throughout 2020/21. As this metric has not been provided previously, further analysis and modelling will be required to confirm the final trajectory for submission in April, taking into account the likely impact of initiatives being delivered now as part of the new service. Out of area Zero by The initial We are committed to improving our out of area placements 2021. priority is to placement position and we have agreed a eliminate revised trajectory with Leeds and York

external Partnership NHS Foundation Trust that out of area demonstrates how we intend to achieve the placements challenge of eliminating the use of out of area by 2021. placements by April 2021. A number of supported accommodation related initiatives are being developed between Leeds CCG and Leeds City Council that will be realised in the first quarter of 2020/21 which will contribute to the reduction of delayed transfers of care from our inpatient services. Mental health 90% 85% At the end of March 2020, LYPFT goes live with data quality a brand new Electronic Patient Record, CareDirector. This is a significant change for staff and there is an expected period where data quality will be of a much lower standard than previously, particularly during Q1 2020/21.

Cancer Cancer 85% 78% by Performance on this target has been particularly Waiting March challenging primarily due to a surge in urological Times - 62 2021; 85% referrals in 2019/20 and the pensions issue this Day GP by March year. A reduction in performance in the first part Referral 2022 of 2020/21 is anticipated. The pension issue remains a risk to achievement if additional sessions cannot be filled. Cancer 90% 75.3% The numbers in this pathway fluctuate Waiting substantially and there is further work to do Times - 62 locally to ensure all onward referral pathways are Day Upgrade correctly identified and allocated as upgrades. It is difficult to predict further performance at this stage, so we are assuming it will be similar to 2019/20. Cancer 2 93% 93% We are expecting to deliver the target despite week wait very substantial increases in demand experienced during 2019/20 at LTHT (10%). We expect further demand in breast and colorectal to stabilise or increase at a lower rate due to the introduction of Symptomatic Faecal Immunochemical Testing and focused breast pathway work/referral refinement with primary care. There is a risk to achievement of the 93% target at LTHT if growth is above 8% and if this is disproportionate to Breast and Colorectal pathways. Cancer 94% 94.7% Performance on this target will continue to be Waiting met; however there is an identified risk with Times - 31 regards to Linac capacity at LTHT. 10% growth Day has been evidenced in radiotherapy in the last Radiotherapy two years. LTHT are currently developing a business case for Linac expansion.

Cancer 70% 70% Current pilot performance is about 79% against Waiting the national standard (not yet confirmed). It is Times – 28 understood that LTHT performance might decline day (Faster as data compliance improves. Diagnostic Standard)

2.3 OVERVIEW OF WORKFORCE All provider trusts are required to submit workforce information and numbers which is a feature of annual planning. Whilst they have provided individual draft submissions, there is considerable further work required before submitting the final planning narrative to the ICS. The Left Shift Blue Print work will also further inform these figures throughout 2020/21.

As part of the workforce submissions, there have been requirements for providers, including primary care, to include information on:  planned service changes that will materially impact the workforce over the next 12 months;  details of plans for shared workforce across providers and primary care, eg pharmacy, physiotherapy, paramedics etc;  information on rotational posts, pooled work schemes and lead employer models;  use of the apprenticeship levy;  new roles and international recruitment;  plans for system working.

Information provided in the draft submission includes:  details of new services to be established as part of the PCN DES in 2020/21 including structured medication reviews; enhanced health in care homes; improved cancer screening and the potential impact on numbers and skill mix of workforce;  increasing the scope and scale of pilots;  information on shared workforce and employer models between PCNs and providers; and  plans for expansion of the Leeds Primary Care workforce training and development hub.

2.4 OVERVIEW OF THE OPERATIONAL FINANCIAL PLAN FOR 2020/21

2.4.1 The first submission of the 2020/21 operational financial plan for NHS Leeds CCG has been prepared in line with national guidance and is set on the basis that the local health system will make appropriate progress in line with NHS long-term priorities

2.4.2 Commissioning intentions assume delivery of key national targets and the local priorities.

2.4.3 The plan forecasts that the CCG will deliver within the required business rules and advised control total as follows:

 Achieve financial improvement trajectory (FIT) of £0.018m as notified by NHS England. This in- year surplus is based on the national market forces factor adjustment, and is a small change from the breakeven position within the long term financial plan submission to the ICS.

 The retained historic cumulative surplus for the CCG continues to be £35.4m (3%) against a national requirement of 1%. The CCG is unable to draw down its historic surplus due to financial pressures across the wider ICS.

 The required contingency reserve has been set at 0.5% (£6.6m) as required. All reserves are phased in month 12 as required by planning guidance.

 Running cost expenditure is planned to remain within the in-year running cost allocation. Agenda for change impact has been accounted for.

 Impact of IRFS 16 is minor for the CCG and is reflected in the plan, and the impact of increased employer pension contributions following revised Government discount rates is assumed to be funded centrally and not out of CCG notified allocations.

 Contract growth includes the impact of national tariff (uplift of 2.5%, inherent efficiency of 1.1%, net of 1.4%) and CQUINS at 1.25%.

 Plan to achieve Mental Health Investment Standard (MHIS), uplift required for Leeds CCG is 5.5% (based on 3.8% programme growth plus an additional 1.7%). Contract negotiations still to conclude suggest that an element of the MHIS will be applied to support the aspects of the contract settlement with Yorkshire Ambulance Service NHS Trust which reflects their support to the MHIS across Yorkshire and the Humber. The CCG's risk management plans mitigate against any impact on the CCG's overall MHIS trajectory.

 Meet Better Care Fund minimum contribution, £58m for Leeds, 5.3% increase. No national additional funding is available to support this in 2020/21.

 QIPP requirement is 1%, £13m.

 As per the guidance the plan does not include anticipated allocations, and associated expenditure, on elements such as extended access or primary care networks.

2.4.4 Income and expenditure impacts of any funding channeled via the ICS, including Long Term Plan funds, are not included in spend trajectories at CCG level. These funds are received at ICS level where the allocation methodology is decided and agreed.

2.4.5 Primary Care Co-commissioned (PCCC) spend is planned to be £1.8m higher than the PCCC allocation, as in 2019/20.

2.4.6 Contract negotiations are ongoing and will be finalised in line with national timescales.

2.4.7 Key financial risks are:

 The CCG plans regarding left shift, relating to Mental Health and Community Sectors in the main, are assumed to be funded through ICS additional allocations. Ambitious left shift plans are dependent on the availability of workforce, which is a key system risk, and also managing expected growth in demand pressures. The extent to which patient activity flows can also be redirected from acute and other hospital settings to outside of hospital will also dictate the ability of the CCG to redirect funding streams to enact the shift. There is inevitably a need to fund transitional double running costs during that process which is likely to require access to the CCG’s historic surpluses.

 To date the lack of access to the historic surpluses has not impacted adversely on the financial position across NHS organisations in Leeds. But with the cessation of the Strategic Transformation Fund support to providers, and to LTHT in particular, it is likely that the CCG will require access to those resources during the four year planning process and specifically as a result of the financial impact of the transition period of building a new hospital in Leeds. The CCG’s expenditure plan is currently significantly lower than LTHT’s income projections over a five year trajectory up to the completion of the new hospital. Longer term financial, activity and capacity modelling due to be completed in early 2020/21 will provide a more informed assessment of the anticipated financial pressures for Leeds. A cornerstone of the LTHT income projection is repatriation of a significant proportion of the £40m activity currently undertaken in the private sector. To ensure that this happens, LTHT needs to be able to release capacity through its continued waste reduction programme and to be able to access its own diagnostic capacity in a timely manner. Currently the restrictions on diagnostic capacity across West Yorkshire adversely impacts on LTHT’s ability to use their overall bed capacity effectively and also impacts adversely on key patient metrics.

 System control totals will be in operation. 50% of the Financial Recovery Fund (FRF) will be tied to system financial performance and not just individual organisation performance. The intention is to increase the proportion of all national funding that goes through the ICS.

2.4.8 The first 2020/21 financial plan submission on 5 March 2020 was based on Month 9 forecast as per national guidance. It is currently unknown which month a forecast will be based upon given NHS England’s announcement on 17 March 2020 to suspend the operational planning process 2020/21. However, annual budgets will be derived from this and will be brought to the next Governing Body meeting for approval.

2.4.9 An extract of the financial plan is attached at Appendix A.

3 NEXT STEPS

3.1 Further work is continuing on the detail on all aspects of the planning requirement – financial, activity, performance and trajectories and workforce.

3.2 It is anticipated that the ICS will provide feedback on the draft submission and further assurance meetings will be held, which will be attended by representatives of the main Leeds partners. These were originally planned for April, but again have been deferred due to the current change in priorities.

3.3 In the event of the revised final submission date restricting our ability to present the final plan to Governing Body for prior approval we are requesting that approval of the final submission is delegated to the CCG Accountable Officer and Chief Finance Officer. A further paper, outlining the final submission, will be brought to the Governing Body in due course.

4 RECOMMENDATION

The Governing Body is asked to:

(c) NOTE and COMMENT on the draft plan; (d) DELEGATE authority to the CCG Accountable Officer and Chief Finance Officer to approve the final submission and associated detailed budgets, in the event of this action being required.

12 Appendix A

NHS LEEDS CCG Forecast Out-turn Plan Financial Plan 2020-21 31/03/2020 31/03/2021 Year Ending Year Ending £000 £000 Revenue Resource Limit Recurrent 1,282,678 1,330,981 Non-Recurrent 28,538 (158) Total In-Year allocation 1,311,216 1,330,823

Expenditure Acute 630,672 631,609 Mental Health 160,382 166,954 Community 144,038 142,362 Continuing Care 53,895 55,194 Primary Care 154,824 154,194 Other Programme 35,619 34,752 Primary Care Co-Commissioning 118,233 123,706 Total Programme Costs 1,297,663 1,308,771 Running Costs 13,553 15,380 Contingency 0 6,654 Total Costs 1,311,216 1,330,805

Underspend/(Deficit) In-Year Movement 0 18 In-Year (RAG) Net Risk/Headroom 0 Risk Adjusted Underspend/(Deficit) 18 Risk Adjusted Underspend/(Deficit) (RAG) Underlying position - Underspend/ (Deficit) 1,963 18 Underlying position - Underspend/ (Deficit) % 0.2% 0.0% Underlying position (RAG) Contingency 0 6,654 Contingency % 0.0% 0.5% Contingency (RAG) Notified Running Cost Allocation 17,436 15,380 Running Cost 13,553 15,380 Under / (Overspend) 3,883 0 Running Costs (RAG) Population Size (000) 885 889 Spend per head (£) 15 17

Key Planning Assumptions Notified Allocation Change (£'000) 41,942 Notified Allocation Change (%) 5.40% 3.6% Tariff Change - Acute (%) 3.60% 1.4% Tariff Change - Non Acute (%) 1.50% 0.7% Demographic Growth (%) 1.20% 0.6% Non Demographic Growth - Acute (%) 3.30% 0.6% Non Demographic Growth - Cont.Care(%) 0.00% 0.0% Non Demographic Growth - Prescribing (%) 0.00% 0.0% Non Demographic Growth - Other Non Acute (%) 0.00% 0.0% Has the Mental Health Investment Standard been met? Net Efficiency Savings Recurrent (inclusive of full year effect) 21,106 12,950 Non-Recurrent 0 0 Total 21,106 12,950 % of Recurrent Notified Resource 1.6% 1.0% Unidentified 0 0 % Unidentified 0.0% 0.0% BCF Minimum Pooled Fund 55,239 58,055 RAG Rating

BALANCE SHEET memorandum - Movement on historic underspend/(deficit)

Brought forward underspend/(deficit) 35,462 35,462 Adjusted for in-year (drawdown) 0 Underspend/(Deficit) In-Year Movement 0 18 Balance carried forward 35,462 35,480 Underspend/(Deficit) % 3.0% 2.9% Underspend (RAG) Allowable drawdown within business rules 23,800 23,371

Agenda Item: GB 19/129 FOI Exempt: N

NHS Leeds CCG Governing Body

Date of meeting: 25th March 2020

Title: Leeds CCG Health Inequalities Framework – principles for investment

Lead Governing Body Member: Katherine Tick as Category of Paper appropriate Sheerin, Director of System Integration () Report Author: Rebecca Barwick, Head of System Integration Decision 

Reviewed by EMT/Date: 4th March 2020 Discussion

Reviewed by Committee/Date: N/A Information

Checked by Finance (Y/N/N/A): N/A Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

NHS Leeds CCG Strategic Commitments We will focus resources to: 1. Deliver better outcomes for people’s health and wellbeing  2. Reduce health inequalities across our city  We will work with our partners and the people of Leeds to: 3. Support a greater focus on the wider determinants of health  4. Increase their confidence to manage their own health and wellbeing  5. Achieve better integrated care for the population of Leeds 6. Create the conditions for health and care needs to be addressed around local  neighbourhoods Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability 4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve  health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions 7. Failure to enable partners to work together to deliver the CCG commitments 8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY:

Following the development of the CCG’s strategic plan, which set out the key aim to reduce health inequalities, work has been underway to develop a strategic response to this aim.

The purpose of this paper to request that the Governing Body sign off the CCG Health Inequalities Framework for Action, a draft of which was brought in draft in July 2019.

The CCG Health Inequalities Framework for Action now includes a set of principles for investment developed in response to the Health Inequalities Framework for Action. The principles for investment are worked examples of how the framework could be best implemented within the CCG.

NEXT STEPS:

Once approved the CCG Health Inequalities Framework for Action will be implemented in the CCG. A process to communicate it and its contents to staff will be developed along with clear expectations of teams. This will be aligned with the ‘Shaping Our Future’ and ‘Left-Shift Blueprint’ process, which have the overall aim of moving to commissioning for population outcomes with a key aim of more effectively improving outcomes and reducing health inequalities.

A key first next step is a public engagement / insight gathering exercise on the principle of ‘proportionate universalism1’ which will take place on Saturday 25th April. We have commissioned QA Research to work with us on this.

RECOMMENDATION:

The Governing Body is asked to:

(a) NOTE the updated CCG Health Inequalities Framework for Action.

1 *Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.” The Marmot Review, 2010

1. SUMMARY

1.1 The purpose of this paper is to request that the Governing Body sign off the CCG Health Inequalities Framework for Action, a draft of which was brought in draft in July 2019.

1.2 The CCG Health Inequalities Framework for Action now includes a set of principles for investment developed in response to the Health Inequalities Framework for Action. The principles for investment are worked examples of how the framework could be best implemented within the CCG.

2. BACKGROUND

2.1 Health inequalities are growing in Leeds, impacting particularly on deprived neighbourhoods and vulnerable and marginalized groups. The CCG has a role in addressing this. The CCG’s strategic plan states that we will focus our resources to reduce health inequalities in Leeds.

2.2 A piece of work has been underway for a number of months to design and describe the CCG’s strategic approach to reducing health inequalities. There have been some examples of excellent practice in the organisation, however a cohesive approach is needed in order to make a greater impact.

3. PROPOSAL

3.1 It is proposed that the CCG agree a set of principles that describe our approach to addressing health inequalities as well as, specifically, how we will use our resources to make the greatest impact.

3.2 The Health Inequalities Framework for Action at Appendix 1 sets out the following principles, as well as providing a detailed context.

 We will focus on reducing Potential Years Life Lost for conditions amendable to healthcare as well as increasing Healthy Life Expectancy  We will focus on deprived Leeds as well as vulnerable and marginalized groups.  In using our resources we will apply principles of ‘proportionate universalism’ to make a greater impact  We will increase our formal partnership working with the local authority to agree joint priorities for funding around prevention and wider determinants of health.  We will make our investment in the third sector more sustainable where there is evidence that this is effective.

4. NEXT STEPS

4.1 Once approved the CCG Health Inequalities Framework for Action will be implemented in the CCG. A process to communicate it and its contents to staff will be developed along with clear expectations of teams. This will be aligned with the ‘Shaping Our Future’ and ‘Left- Shift Blueprint’ process, which have the overall aim of moving to commissioning for

population outcomes with a key aim of more effectively improving outcomes and reducing health inequalities. . 5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 The CCG has a statutory duty to reduce health inequalities and is held to account on Potential years Life Lost for conditions amendable to

6. FINANCIAL IMPLICATIONS AND RISK

6.1 There are a number of perceived risks which will need to be worked through:

• Impact may not be seen for many years • May impact negatively on NHS Oversight Framework indicators (and CCG’s rating) • Vulnerable and marginalised groups are small in numbers and may not show up the data • Investment in small third sector organisations may carry a greater financial governance risk than, for example, working with other NHS organisations

7. COMMUNICATIONS AND INVOLVEMENT

7.1 A key first next step is a public engagement exercise on the principle of ‘proportionate universalism’ which will take place on Saturday 25th April.

8. WORKFORCE

8.1 There are no specific workforce issues.

9. EQUALITY IMPACT ASSESSMENT

9.1 Commissioning schemes are required to undertake EIAs. Ensuring that and EIA has taken place will be one of the mechanisms of implementing this framework.

10. ENVIRONMENTAL

10.1 There are no specific environmental issues.

11. RECOMMENDATION

The Governing Body is asked to:

a) APPROVE the CCG Health Inequalities Framework for Action

Health Inequalities Our Framework for Action

March 2020 Health Inequalities Our Framework for Action

Contents

1. Introduction...... 1 2. National context ...... 2 3. Principles for our approach in Leeds...... 2 4. What is the local picture of inequalities?...... 3 5. Key factors that lead to health inequalities...... 4 6. Our framework for action...... 6 7. Using our resources...... 9 8. What would this look like in practice? ...... 10 9. How will we measure impact?...... 11 10. Conclusion...... 12 1. Introduction

For many years, the NHS has worked with But in Leeds, it is not just a legal duty that partners to tackle health inequalities. drives us. We set out in our Strategic Plan Indeed, CCGs, like PCTs before them, have (July 2018) how we will respond to the Health a legal duty to respond to inequalities in the and Wellbeing ambition that ‘Leeds will be health of their populations, both in terms a healthy and caring city for people of all of access to services and outcomes on life ages where people who are the poorest expectancy. For most of the 20th Century, improve their health the fastest’. This included the life expectancy and health experience committing to focusing resources to deliver between the least healthy people in society better outcomes for people’s health and well- and the healthiest has narrowed, largely due being and to reduce health inequalities across to the impact of the economy, public health our city. initiatives and the availability of high quality This framework for action describes how the care for all delivered through the NHS. CCG will use its £1.3bn resource to drive the However, in more recent times this gap is changes needed to realise this aim. However, widening. There is significant speculation it is also sets out how the CCG will use its about why this is happening, though there position as a major statutory body to influence is evidence that the changing nature of the wider determinants of health and our communities, immigration, the increasing partners in ways which more positively impact wealth of the healthiest and, most on the inequalities faced by the poorest significantly, the impact of austerity have all people in the city. 1 contributed . So the challenge to respond to health inequalities and meet our legal duty has never been greater.

1 2. National context 3. Principles for our approach in Leeds There is a growing sense that the NHS (commissioners and providers) needs to work with partners to address the health Our shared Health and Wellbeing vision is inequalities faced by local people. The Long that - Term Plan Implementation Guidance (June ‘Leeds will be a healthy and caring city 2019) sets out the following - for all ages where people who are the ‘Over the next five and ten years the poorest improve their health the fastest.’ NHS will progressively increase its … is underpinned by the following principle focus on prevention and ensure that which guides how we work - inequalities reduction is at the centre of ‘We put people first. We work with all our plans.’ people, instead of doing things to them … and that - or for them, maximising the assets, ‘The Government’s Prevention Green strengths and skills of Leeds citizens and Paper (published in July 2019 2) provides our workforce.’ further opportunities for the NHS and This is essential to our approach in addressing Government to go further, faster, in health inequalities in the city. We will fail prevention and inequality reduction and if we do not work with people in full, as will feed into future iterations of system we cannot understand their lives, their plans.’ motivations, their challenges. And we will fail The Plan also describes how the NHS needs if we don’t recognise the incredible strengths to support wider social goals through of all communities in the city, and work with employment, work to tackle climate change people to build from these. and to maximise its contribution to social value as ‘anchor institutions’. As more collaborative approaches emerge across providers, with more provider- led service re-design undertaken across organisations, there will be a growing emphasis for providers to not just respond to the people who present, but to ensure that services reach out and meet the needs of all people. CCGs will need to ensure this proactive approach is strengthened, setting outcomes which result in improved health and services for the most disadvantaged communities and groups.

2 4. What is the local picture of inequalities? Who is affected?

In order to address health inequalities, Leeds Vulnerable and marginalised populations reside has identified the people in the city living in in all geographical areas, deprived and more the 10% most deprived areas nationally affluent, however there is increased impact for as a priority for action. This equates to people who are also living in deprivation. 224,000 people, with almost 80% living in Figure 1 below describes how vulnerability 3 the following 7 Local Care Partnerships : combines the protected characteristics with the • Harehills factors relating to where you live and how you • Chapeltown are treated within society. • Middleton

• Burmantofts and Richmond Hill poverty, education, employment and housing Where you live: Geography • Beeston Socio-economic factors, including • Seacroft • Armley • Central. The more There is a wealth of information about the factors, the differences in health experienced by this Who you are: Demographicsincreased vulnerability Age, gender, disability, ethnicity, group of people, with some interesting sexuality, religion and faithor beliefs risk of poor health points to note: outcomes, including chronic long-term conditions • 25% of people live in ‘deprived Leeds’ and lower life expectancy. • 28% of preventable life years lost are for people living in these areas. How people treat you Cancer, CVD and respiratory still account Stigma and discrimination for the most deaths for people living in (on an individual and institutional level) ‘deprived Leeds’. In addition there are a number of particular outliers in these areas Vulnerable and marginalised populations in terms of causes of avoidable death for include people from black and minority example, infections, maternal infant and ethnic groups, gypsies and travellers, the neurological illnesses. unemployed, homeless, looked after In addition to geographic inequalities, we children, the homeless, people living with also need to consider the challenges faced learning disabilities and people living with by marginalised and vulnerable groups severe mental illness. of people as there is significant evidence And whilst these two categories (geographic that vulnerable and marginalised groups and vulnerable groups) are useful to help to have significantlyworse health outcomes shape our work, they are not exhaustive and than the general population. we cannot ignore other groups / areas of the city given that the health outcomes in Leeds as a whole are often poorer than those of England.

3 5. Key Factors that lead to health inequalities

Figure 2 below frames the key factors that lead to health inequalities:

BAL ECOSYST GLO EM URAL ENVIRONME NAT NT T ENVIRONM BUIL ENT ACTIVITIES ND CARE H A SYS LT T S EA EM h H o g L ECONO p e in CA M p c c LO Y i B a s n n p e g A I e i O s c MUNI , i r OM TY S r a e C p , e l M t D p e l r w u p a a e l x n y , s i e a I b e p VING n V s i I i L g n t t E , , h , e s S J s e s h p g E g n m o , T t y u r t l o t i o b , , m n i r t R k a i a t v p i s l r l A o a i t t n o e l t , e a a i e c g s S h a PEOPLE e w a n r , v w a b , M , , a I p l r , s e d l c o T I a s i c n k a i e l o v c r c r h g L i i i Y i h k o c n

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It is estimated that only 20% of health outcomes result from clinical interventions with the remaining 80% driven by healthy lifestyle factors; wider determinants of health, such as social networks and environmental factors

4 How to tackle health inequalities Given the above, it is clear that we need to address health inequalities at three levels - A: Wider Determinants: Actions to improve ‘the causes of the causes’ such as increasing access to good work, improving skills, housing and the provision and quality of green space and other public spaces and Best Start initiatives. B: Prevention: Actions to reduce the causes, such as improving healthy lifestyles - (stopping smoking, a healthy diet and reducing harmful alcohol use and increasing physical activity). C: Access to effective Treatment, Care and Support: Actions to improve the provision of and access to healthcare and the types of interventions planned for all - for example ensuring health literacy is supportive; ensuring there are health inequalities impacts for all commissioned services.

5 6. Our Framework for action

Our overarching approach will be to facilitate We will ensure that our estates planning key stakeholders to collaborate to improve and investment optimises the health effects quality, problem solve together and share of the built environment, and will always look collective outcomes with a view to moving for and take opportunities to co-ordinate care upstream and implementing innovative resources with partners to maximise impact. solutions to addressing health inequalities. Prevention Figure 3 below describes the three elements outlined above and sets out principles for We will work with Public Health how we use our resources (people, time and colleagues to ensure that the NHS money) to take action to address inequalities maximises its contribution to prevention through the contracts we have with providers. This will include building preventive approaches into pathways, and ensuring that NHS staff have access to prevention and wellbeing services. We will support investment in evidence Wider based prevention services where we know determinants Prevention this will improve health outcomes, and will focus this investment in the most deprived RESOURCES areas of the city and with marginalised and vulnerable groups. This should include : • Smoking cessation • Schemes to promote increased physical Treatment - design, activity access and delivery • Best Start programmes • Other wellbeing schemes which address mental health • Targeted prevention programmes which For each specific element described in Figure promote healthy ageing, and which 3 above, we will take the following actions: support people known to be at high risk of developing long term physical and mental Wider Determinants health conditions We will work with partners to ensure that the work of the CCG delivers a wider social impact, including on the employment of local people, housing (e.g fuel poverty), air pollution and transport, all of which disproportionately affect the poorest in society.

6 Treatment - Service ensure that provision reaches out and meets We need to take a stronger approach to the needs of all people in the community, in service design, access and delivery to tackle particular those facing disadvantage. health inequalities, in particular for those Treatment - Access conditions which people from vulnerable groups or the poorest parts of the city are We will ensure that services are delivered dying of earlier, including cancer, CVD, in ways which optimises access for respiratory disease, etc. people from disadvantaged groups. This included considering geography, transport, For new services: buildings; health literacy and digital We will start with the question how does inclusion. this reduce health inequalities when In order to understand this, we will commissioning or redesigning services (rather continuously review access levels to services than just thinking about how a new services to ensure that current arrangements do not doesn’t increase health inequalities). In all further disadvantage people experiencing the cases we will consider disproportionate poorest health. funding services targeted in specific areas and at specific groups where appropriate. Treatment - Delivery We will identify the people who currently Proactive Preventative Care have the poorest outcomes and ensure that Key to addressing health inequalities will their voices are central to how the new be the early identification of people at risk services are commissioned, with a much of or in the early stages of illnesses. We stronger emphasis on co-production. will continue to strengthen our Quality We will increasingly work through Local Improvement Scheme in General Practice so Care Partnerships (with particular that people are identified and supported to emphasis on those supporting people manage their condition at the earliest possible in the most deprived areas), supporting stage, but with a greater focus on practices a locally driven population health working in the most deprived areas. This will management approach to service redesign. also include far greater focus on ensuring that We will build in performance measures people with Learning Disabilities and Mental to all new contracts to ensure that outcomes Health issues and carers have health checks for people currently experiencing the poorest with appropriate care and support plans. health are improved. Pathway Improvement For existing services: We will support an approach to care and We will develop key measures to assess disease pathway improvement (e.g. diabetes) how well services are performing in the that focusses on bringing together key poorest areas of the city and with the most clinicians and professionals across primary, vulnerable groups community and secondary care. We recognise that these functions will There will be an emphasis on problem increasingly be vested in providers; our role solving, quality improvement and developing as a CCG will be to ensure that the right skills shared objectives with a view to making a and approaches are transferred in order to greater impact on deprived communities. This will be underpinned by a population health management approach.

7 Local Care Partnerships A Stronger Partnership with 3rd Sector Our key vehicle for tackling health inequalities We will act to ensure that the strong, vibrant are the Local Care Partnerships, especially and diverse third sector of community and those serving the most deprived areas. LCPs voluntary organisations continues to be bring together health, social care, local at the heart of care and support services community / voluntary organisations and local being provided in the city. This will include people to design services responsive to the investment and support so that as well as local community. being key providers of services, our third There are 18 LCPs in the city, with 7 covering sector organisations are actively contributing the majority of those communities living to and informing the development of health in the most deprived areas. And we have and care services across the city and in local supported their development be investing in communities. This will have a particular leadership and empowering them through emphasis on the role of the third sector in the development of population health supporting people in the most vulnerable management skills. We see that they will groups and living complex lives in areas of increasingly be the footprint for the delivery deprivation. of integrated services, and will take on more ‘commissioning’ responsibilities - that is designing and delivering services to meet improved health outcomes. Our LCPs will now be underpinned by PCNs, thus strengthening their ability to come together and deliver change. These new arrangements give us a great opportunity to support the redesign of services in a way which meets more local needs and so helps to address health inequalities, and we will ensure this is maximised.

8 7. Using our resources

We will focus our resources to address health Learning can be drawn from the way that inequalities: Children’s work is organised in Leeds. Using a population approach means that We will have a targeted approach, commissioners from health and other parts applying the principle of ‘proportionate of the system are able to agree and work universalism’ 4: towards joint priorities and ‘obsessions’ There is an existing agreed scheme to reinvest through the Children and Young People Primary Medical Services (PMS) monies in Board at which all stakeholders are general practice in Leeds. For an agreed set represented. This population approach could of outcomes relating to health inequalities a be extended to the other population segment formula has been agreed using proportionate agreed as part of the population outcomes universalism to target investment. This work. has been developed using the ‘Car-Hill’ formula (widely accepted as not adequately We will invest in third sector sustainably reflecting additional input needed for primary where there is evidence that this is an prevention associated with deprivation levels) effective approach: and adding in ethnicity as a way to reflect We know that partnerships with the local deprivation. This scheme could be further third sector are crucial in reaching vulnerable developed and built upon to have more of and marginalised groups, who may be very an emphasis on deprivation and vulnerable small, hidden and will be hard to reach. We groups. A core principle would be that actions are reliant on a sustainable third sector if we and interventions would be decided at PCN/ want to reach these groups and address the LCP level, but with outcomes set that required health inequalities that they experience. a focus on deprivation and vulnerable groups. Where there is evidence that partnering We will have a partnership approach to with third sector organisations will have an prevention and wider determinants of impact on reducing health inequalities, we health: will strengthen our contracting arrangements The lead for most areas of prevention and ensuring that these organisations are able to wider determinants is held by Leeds City sustain their vital, work with specific groups. Council. Where the CCG and Leeds City Council agree on a set of shared priorities there could be joint investment and actions in a number of areas that directly affect health services e.g. housing, drug and alcohol, employment, poverty etc. This could be approached using existing forums (e.g. Integrated Commissioning Executive - ICE) to agree priorities.

9 8. What could this look like in practice?

There are many ways that these principles could be applied in our work. Here are two examples of how this strategy could work in practice. a) Diabetes Pathway b) Smoking Cessation

CCG implements aligned outcomes contract CCG & Leeds City Council agree with multiple primary, community and Smoking Cessation as a joint priority secondary providers across the pathway. and agree a joint investment plan.

Contractual requirements include the need Joint investment agreed, applying to provide greater concentration of service proportionate unversalism directly into LCPs. provision to most deprived areas.

Actions agreed by LCPs using local intelligence Clinicians and professionals across pathway in partnership with local third sector use local intelligence to probelm-solve, achieve organistaions to reach most vulnerable. ‘left-shift’ and reach harder to reach groups.

Outcome: increased number of quitters Outcome: Disease is prevented and identified leading to faster decrease in PYLL in most earlier. PYLL gap closes faster in most deprived deprived areas and HLE overall improves. areas and HLE overall improves.

So as a commissioner, we will ensure that So as a commissioner, we will work with our contracts promote provider responsibility Public Health colleagues to invest in for addressing health inequalities, bringing additional preventive services which enable clinicians from across primary and secondary improved health outcomes for deprived and care together to design services which disadvantaged groups of people. respond effectively to more local needs. We will also ensure that contracts engineer providers to work together across care pathways, and to bring in community / 3rd sector organisations in delivery to help with addressing inequalities. This will be reflected in how we work as a CCG going forward, with a more strategic approach to commissioning and a bigger role in supporting integration of services across providers. This is being described in the ‘Shaping Our Future’ programme.

10 9. How will we measure the impact?

Our Health Inequalities outcome focus is years people live in good health, particularly on reducing Potential Years Life Lost for for those from deprived communities and conditions amendable to healthcare (PYLL) vulnerable groups. and Healthy Life Expectancy (HLE) However, we need to work with people to Our aim is to close the PYLL gap of Leeds develop outcome measures which matter compared to the national average as well as to them. And we would need to compare increasing overall HLE. Additional we aim to progress in the 7 LCPs with the highest close the PYLL gap within the most deprived number of people living in deprivation, as communities faster than the non-deprived well as by different vulnerable groups where areas. appropriate and possible. In order to understand progress, a small The measures for this framework will align number of measures which capture the with the Health Outcomes Ambitions described impact of our actions have been developed in the CCG’s ‘Left-Shift Blueprint’, our 5 year as part of the ‘Left-Shift Blueprint’, the CCG’s strategic commissioning and investment plan. 5-year investment plan. We are working to set specific ambitions for As part of the CCG’s Strategic Plan, we these outcomes which will describe the impact committed to lead action against a number of we will make for Leeds as a whole (compared the Health and Wellbeing Strategy indicators: to the national average) as well as within Leeds (to narrow the gap between the 10% most There is also a growing emphasis on healthy deprived communities and the Leeds average). life expectancy - increasing the number of This is our proposed measurement framework:

Measure By LCP By vulnerable group Improve infant mortality and narrow the gap Yes Yes Reduce weight in 10-11 year olds Yes Yes Reduce suicide rate Yes Yes Reduce PYLL for conditions amendable to Yes Yes healthcare Reduce early rate of early deaths: CVD, Yes Yes cancer, respiratory, liver disease Reduce mortality for those with LD and SMI Yes Yes Data not available at Data not available at Increase Healthy Life Expectancy LCP level - citywide LCP level - citywide aggregate only aggregate only

11 The specific measures will be developed over 10. Conclusion the coming months and years, recognising that developing outcomes which matter to different groups of people will take time. NHS Leeds CCG recognises the health The metrics will also be built into provider inequalities in our city. We also recognise contracts in order that services are that we can have a significant role to play in continuously shaped for people who have addressing these, both in how we work with the greatest inequalities and commissioning partners and how we use our commissioning teams will be held to account for this as part resources. of internal commissioning processes. We know that we are building on great previous work, and we know that it will take time to achieve change. However, we now want to take a more coherent and ambitious approach to tackling health inequalities in order to make a reality of the vision that ‘people who are the poorest improve their health the fastest’.

12 13 NHS Leeds CCG Suites 2-4 WIRA House West Park Ring Road Leeds LS16 6EB  www.leedsccg.nhs.uk  [email protected]  facebook.com/nhsleeds  twitter.com/nhsleeds

Agenda Item: GB 19/130 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting

Date of meeting: 25 March 2020 Title: Chair’s Summary – Primary Care Commissioning Committee held on 5 February 2020 Lead Governing Body Member: Sam Tick as Senior, Lay Member & Chair – Primary Care Category of paper appropriate Commissioning Committee () Report Author: Karen Lambe, Corporate Decision Governance Officer Discussion  Information Approved by Lead Governing Body Member (Y/N) Y EXECUTIVE SUMMARY: This report provides the NHS Leeds CCG Governing Body with a summary of items discussed and outcomes and risks identified at the Primary Care Commissioning Committee (PCCC) meeting held on 5 February 2020.

RECOMMENDATION: The Governing Body is asked to:

(a) RECEIVE the report.

Description of key items of business discussed and key outcomes 1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the PCCC meeting held on 5 February 2020. Further information can be obtained by reference to the minutes of that meeting.

Chief Executive’s Update 2. Members were updated on the delayed NHS Operational Planning and Contracting Guidance for 2020/21. Written responses from West Yorkshire would be submitted in the following few weeks and would reflect the CCG’s expectations regarding Primary Care Networks (PCNs). It was acknowledged that there would be a tight turnaround for responses.

3. The CCG was reviewing its role in the city in consultation with its staff and partners, as part of its ‘Shaping Our Futures’ project to improve health outcomes and reduce inequalities.

4. Following a recent recruitment process, the NHS Leeds Health & Care Academy had been unsuccessful in appointing a lead to address NHS workforce issues. The role would be readvertised in the near future.

Primary Care Networks Update 5. Assurance was given that all PCNs had submitted their spending plans prior to the release

of funding. PCNs were planning regular forums for Clinical Directors (CDs) to review priorities and share knowledge. Providers’ Chief Executive Officers had been invited to meet with CDs for strategic discussions.

6. There had been significant local and national concern regarding the PCN Directed Enhanced Services (DES) draft specifications, particularly due to lack of capacity and short timescales. A response had been submitted by Leeds GP Confederation and Leeds Local Medical Council (LMC) on behalf of the city’s general practices. The final DES draft specifications were likely to be delayed until March 2020. It was noted that the delay was problematic for PCNs in terms of their decision making and what would be expected of the additional roles.

7. In terms of the additional roles reimbursement scheme, 15 social prescribing link workers and 15 clinical pharmacists had been recruited. Assurance was given that work was ongoing to recruit physiotherapists and rotational paramedics for 2020/21. The committee discussed the potential impact that recruitment of additional rotational paramedics by PCNs could have on the Yorkshire Ambulance Service (YAS).

Proposal to Commence Patient Engagement – Alwoodley Medical Centre 8. The CCG had received an application on behalf of Alwoodley Medical Centre in its proposal to carry out a patient engagement on the proposed closure of its branch surgery in Adel. The Adel Surgery served a patient list of approximately 2500, following a merger with Moorcroft Surgery in 2016. It was noted that Adel Surgery’s list size had not increased despite new housing developments in the area. Alwoodley Medical Centre reported that, due to the high demand for appointments at its Moortown site, the Adel Surgery was being utilised to absorb the excess appointments. In its application, Alwoodley Medical Centre cited concerns that the premises in Adel were not fit for purpose, offering limited availability to clinicians. The lease on the premises was due to expire in March 2021. The committee noted that potential consolidation of both sites would better utilise clinician time and improve practice resilience and sustainability.

9. The committee was required to decide whether it supported Alwoodley Medical Centre in carrying out a patient engagement. The role of the CCG Engagement team would be to provide the tools to facilitate the engagement. The practice Patient Participation Group (PPG) would provide assurance that the engagement was robust. The intention of the consultation would be to assess the impact of changes and to inform the CCG’s future commissioning intentions. Following consideration, the Primary Care Operation Group (PCOG) on 22 January 2020 had supported the carrying out of patient engagement.

10. The committee discussed a number of issues affecting the surgery. No GPs worked solely at the Adel Surgery; rather, GPs worked across both sites. The practice had confirmed that following consultation with other local practices, there was sufficient capacity to absorb all of Adel Surgery’s patients, but this would need to be considered further following the engagement period. Further assurance was given that, in the event of the closure of Adel Surgery, there would be additional appointment capacity at Alwoodley Medical Centre.

11. The patient engagement would commence in February/ March 2020, with both practices contacting all registered patients. The outcome of the engagement would be reported

publically in a ‘You Said, We Did’ format. Concern was expressed for patients who may experience access difficulties to Alwoodley Medical Centre in the event of closure of the Adel Surgery. The need for all patients to engage in the consultation in order to express their needs and priorities was highlighted. The outcome of the public engagement would be considered alongside information concerning population growth and demographics.

12. A petition objecting to the proposed closure of Adel Surgery was presented to the PCCC by Nick Rutherford from the office of MP Alex Sobel, Leeds North West. The petition was accepted by the Chief Executive Officer of NHS Leeds CCG.

Allerton Medical Centre and Westfield Medical Centre – Proposed Merger 13. Both practices were based in the Chapeltown PCN 0.7 miles apart and had worked with neighbouring practices for a number of years. It was noted that the two practices were in the process of completing a full business merger; a contractual merger would further support the integration of the process and help ensure the sustainability of both practices. The committee commended the excellent patient engagement carried out by the practices. Having acknowledged that the merger would be a positive step in increasing the resilience of both practices, the PCCC approved the merger.

Primary Care Enhanced Specifications Proposals 2020/21 14. A number of changes to the Quality Improvement Scheme (QIS) were recommended following consultation with Clinical Leads for Long Term Conditions, Older People and End of Life. End of Life improvements had been added to the scheme.

15. With regards to Learning Disability (LD) health checks, these had not been finalised in the Quality Outcomes Framework (QOF). Assurance was given that the CCG would align payment with the achievement of the target, whether it was part of the QIS or the QOF.

16. Due to delays in the DES specifications, it was recommended that the Enhanced Care Home Scheme be recommissioned to current providers for a further year. The current scheme was run by 49 practices. The additional transitional year would allow sufficient time to work through workforce and workload issues. The CCG would work with CDs to review pathways for vulnerable populations.

APMS Contract Extension of York Street Health Practice 17. The committee was updated on the Alternative Provider Medical Services (APMS) contract held by Bevan Healthcare for the York Street Health Practice. The contract, awarded following procurement in 2016/17, was for three years plus two years. It was noted that the practice supported Leeds City Council street worker services and provided bespoke primary care with outreach to a number of vulnerable populations. Both the provider and the CCG Primary Care team were supportive of extending the contract to the end of the three plus two years’ term. The rolling over of the contract would provide an opportunity to review the service specification in the light of the CCG’s ambition to move towards a population health needs approach.

Review of Domiciliary Phlebotomy 18. Following a service review of the domiciliary phlebotomy service previously commissioned by NHS Leeds South and East CCG, the Primary Care Operational Group (PCOG) had

recommended the decommissioning of the service due to not demonstrating best practice or value for money. Members acknowledged that the service was the last historic legacy issue of inequality. The committee discussed the potential duplication of the service for patients with dementia as it was included within the core general practice contract and the healthy living initiative offered by the practice. Members were assured that the service would continue to be delivered and this would be communicated to patients. The importance of seeing vulnerable patients at home was recognised.

Health Inequalities Audit 2019 – Access to General Practice 19. The action plan for the Health Inequalities Audit was presented to the committee. In relation to the improvement to access to routine appointments, an access steering group had been established in collaboration with the GP Confederation. It was noted that reporting of ethnicity had increased by 7% and first language had increased by 8%. Focussed attention on LD was also highlighted. Improved recording of information would enable practices to better meet the needs of their populations.

Chair’s Summary from the Quality & Performance Committee meeting held on 15 January 2020 20. An update was provided in relation to the coronavirus and it was confirmed that there had been no increased demand as yet.

Primary Care Integrated Quality & Performance Report (IQPR) 21. In relation to flu vaccinations, there had been a significant improvement in some areas for patients over 65, at risk patients 41% and pregnant women 47%. There was recognition that there had been issues with supply. Members were informed that no correlation between supply difficulties and increased incidences had been recognised. Assurance was given that the campaign was running longer than it normally would to reach those that had not yet had their vaccination

22. The committee noted that 99% of practices were rated Good or Outstanding and that this was a continuous improvement cycle with Care Quality Commission (CQC) inspections.

Primary Care Risk Report 23. Members noted a new risk in relation to procurement. The risk was scored at 8 and therefore was for information only. Risk 651: General Practice Workforce was reported to the committee as the current score was high amber (12). An update was provided on this risk and it was highlighted that the One Workforce Board had been established which sat across the health and care system and recognised the scale of workforce. In addition, a change in the training hubs which had expanded to the workforce and development hub was reported. Pockets of risk within the workforce were highlighted in terms of an ageing workforce and attracting new GPs. However members were assured that the system was well sighted on these and these were nationally recognised issues in relation to workforce challenges.

Primary Care Finance and Estates Update 24. The CCG was forecasting an underspend of £500k in relation to payments to the PCNs, largely due to time delays in recruiting staff. Nationally, CCGs were asked to put in place local schemes to share the unused funding across the PCNs.

25. With regards to the prescribing budget, forecasting had proved challenging due to Brexit implications. However the CCG planned to hit the forecast position. Assurance was given that further horizon scanning would be done when setting future prescribing budgets.

Any Other Business 26. An update was provided on the proposal to close the dispensary at Harewood Surgery. Following the conclusion of the practice engagement, responses had been collated and shared with NHS England (NHSE) and PCOG. NHSE had taken a paper to their regional Primary Care Commissioning Committee in January 2020 and agreed to support the proposal to close the dispensary.

27. Harewood Surgery had communicated with all patients to inform them that the dispensary service would be closing at the end of March 2020. NHSE had updated the Health and Wellbeing Board and would work with local community pharmacists in the area. However the committee was assured there were no concerns regarding capacity.

Strategies/Policies approved N/A

Items for escalation to the Governing Body The Committee agreed that the following actions would be escalated to the Governing Body for information:

 Learning Disabilities health checks to be reviewed at the Quality & Performance Committee

 Detailed data regarding vaccination uptake would be presented and considered at the Primary Care Operational Group.

THIS PAGE IS INTENTIONALLY BLANK

Agenda Item: GB 19/131 FOI Exempt: N

NHS Leeds CCG Governing Body

Date of meeting: 25 March 2020 Title: Chair’s Summary of Remuneration & Nomination Committee Meeting held on 12 February 2020 Lead Governing Body Member: Sam Senior, Lay Tick as Member – Primary Care Co-Commissioning / Category of Paper appropriate Deputy Chair () Report Author: Laura Parsons, Head of Corporate Decision Governance & Risk Discussion  Information Approved by Lead Governing Body member (Y/N): TBC EXECUTIVE SUMMARY: 1. This report provides the NHS Leeds CCG Governing Body with a summary of items discussed, outcomes and risks identified at the Remuneration & Nomination Committee meeting held on 12 February 2020.

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the report.

Description of key items of business discussed 1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Remuneration & Nomination Committee on 12 February 2020. Further information can be obtained by reference to the minutes of that meeting (subject to exemptions under the Freedom of Information Act).

HR Policies Update 2. The Committee was informed that a Social Partnership Forum (SPF) had now been established for the CCG. The SPF would review any proposed amendments to HR policies prior to being submitted to the Committee for approval.

Domestic Abuse Policy

3. The Committee approved the Domestic Abuse Policy for CCG staff. Members commended this policy and supported its communication across the CCG. The Safeguarding Team would support line managers and staff in using this policy.

Governing Body & VSM Remuneration

4. The Committee considered an annual pay uplift for 2020/21 in relation to Governing Body members. A recommendation was agreed for the Governing Body to consider (see agenda item GB19/42).

Composition of Governing Body & Succession Planning 5. It was agreed that the composition of the Governing Body would be considered further in

June 2020, following the development of a target operating model as part of the Shaping Our Future project.

Gender Pay Gap Report 6. The Gender Pay Gap report was presented and it was noted that the overall gap had reduced since the previous year, but remained high at 29.4%. The median had reduced more markedly from 24.5% to 15.7%. It was agreed that some further analysis would be undertaken and presented at a future meeting, including a comparison to other organisations.

Executive Staffing Update 7. The Committee was informed of the latest position relating to the Executive team and some interim appointments. The Committee was supportive of these appointments and agreed that it would not be appropriate to make permanent appointments at the current time due to the ongoing work to develop a new operating model for the CCG.

Strategies/Policies approved Domestic Abuse Policy for CCG staff.

Items of positive assurance or issues to be raised with the NHS Leeds CCG Governing Body N/A

Any other Comments N/A

Agenda Item: GB 19/132 FOI Exempt: No

NHS Leeds CCG Governing Body

Date of meeting: 25 March 2020 Title: Chair’s Summary of Quality & Performance Committee Meeting held on 11 March 2020 Lead Board Member: Angela Collins, Deputy Tick as Chair and Lay Member for Public & Patient Category of Paper appropriate Participation () Report Author: Karen Lambe, Corporate Decision Governance Officer / Laura Parsons, Head of Discussion  Corporate Governance & Risk Information Approved by Lead Board member (Y/N): Y

EXECUTIVE SUMMARY: 1. This report provides the NHS Leeds CCG Governing Body with a summary of items discussed at the Quality & Performance Committee meeting held on 11 March 2020.

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the report.

Description of key items of business discussed 1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Quality & Performance Committee on 11 March 2020. Further information can be obtained by reference to the minutes of that meeting.

Matters Arising: Verbal Update on COVID-19 2. The Committee was updated on the work of the CCG’s Unplanned Care team and its response to COVID-19, which was a level four situation being directed by NHS England (NHSE). Leeds CCG was a category two responder in its supporting role in bringing the system together. Assurance was given that the team was liaising with the CCG’s Primary Care, Quality and Engagement & Communications teams. The CCG was also actively participating daily in wider health and care forums.

3. A key area of activity was community swabbing, which was well underway with the Leeds Community Healthcare NHS Trust (LCH) team. The 111 service was the medical gateway for bookings, while Leeds Teaching Hospitals NHS Trust (LTHT) was the co-ordination hub.

4. Some concern was expressed regarding inappropriate referrals and confused information for patients. Members were assured that failings within the pathway would be unpicked and addressed.

5. With regards to elective surgery, there had been some cancellations and a number of patients had opted to postpone on advice from their GPs. It was noted that no national guidance on cancellations had been issued as yet.

6. Assurance was given that partnership working was well underway. This included ensuring local authority assistance to patients who were self-isolating or had tested positive with their domiciliary requirements. End of Life providers were also actively participating in the partnership. Assurance was given that Leeds was well prepared in its planning for the continuation of care.

7. The CCG was responsible for communications between NHSE and the individual practices to ensure consistency and a controlled flow of information. Practices were discouraging online bookings for face-to-face appointments and were encouraging telephone appointments.

Emergency Planning – Provider Arrangements

8. The Committee was updated on the Emergency Preparedness, Resilience and Response (EPRR) responsibilities and the controls in place to provide assurance that the CCG’s main providers had robust emergency planning procedures in place. Following self-assessment, the current levels of compliance were: LTHT – substantial; LCH – partial; Leeds & York Partnership NHS Foundation Trust (LYPFT) – substantial; Local Care Direct – substantial; Yorkshire Ambulance Service (YAS) – substantial. With regards to LCH’s reduced rating to partial, assurance was given that this was due to the detail of the evidence required for a number of standards. Members noted that, while it remained difficult to cover all eventualities, CCG plans were broadening to ensure that access to premises, workforce issues and loss of providers were addressed in emergencies.

Integrated Quality & Performance Report (IQPR)

9. With regards to Learning Disabilities health checks (LD), members discussed the need to balance local data with national figures. Local data was recognised as being useful for practices levelling up. While the inclusion of the LD targets in the Quality Improvement Scheme (QIS) had resulted in some duplication, it also offered additional assurance. The fluid nature of the LD register was a challenge in terms of defining numbers. It was acknowledged that, while 75% of people with LD were included on the register, the real ambition was 100%. The updated figure for Severe Mental Illness (SMI) health checks was 60.2% against a target of 60%. The committee acknowledged the impact of the QIS in achieving this.

10. With regards to online consultations, members noted that issues with procurement had impacted on the figures. While 100% coverage was unlikely to be achieved by the end of the year, one third of patients were registered for online services.

Providers Under Enhanced Monitoring

11. The Committee received a summary of the providers that were currently under Routine+ Monitoring, Enhanced Monitoring and Formal Action and the actions being taken as a

result. It was noted that there were no significant changes in terms of benchmarking.

12. The CCG approach to monitoring quality for care homes facing workforce challenges was discussed. Assurance was given that monthly meetings were being held with Leeds City Council and Care Quality Commission (CQC). The impact of COVID-19 on care home workforces was considered and acknowledged as a system resilience issue. Members identified the need for joined up working between the CCG’s Unplanned Care team and the Quality team. Members agreed that they were fully assured on the Quality Surveillance system in place. However, the workforce element remained a concern.

Patient Experience Update Q3

13. The Committee was provided with an overview of patient experience intelligence received during quarter 3 (October – December 2019), and was informed that the Patient Experience Collaborative (PEC) had been established to replace the Patient Insight Group. Members discussed the role of the CCG and the PEC in bringing patient feedback together from different providers and reviewing it from a system perspective. An ‘integration index’ was being developed for the ICS which would support this.

CCG Risk Register

14. Members were informed that three high amber risks had reduced in score since the previous meeting, and two high amber risks had been closed as they related to performance issues rather than risks. Since the papers had been circulated, a new high amber risk had been added to the risk register in relation to Deprivation of Liberty Safeguards (DOLS) and a lack of assessor capacity and availability of court of protection time. This was a national concern and a simplified process was due to be introduced from October 2020 which would help to address the current issues.

Review of Frequency of the CCG Safeguarding Committee

15. It was proposed to reduce the frequency of CCG Safeguarding Committee meetings from bi-monthly to quarterly to ensure better alignment with other external and internal meetings and improve efficiency in reporting. This proposal was approved by the Quality & Performance Committee.

Annual Review of Committee Effectiveness and Terms of Reference

16. The Committee approved its annual report for submission to the Audit Committee and Governing Body. The feedback from the effectiveness survey was largely positive, and it was acknowledged that a review process was already underway in order to improve the Committee and ensure it was aligned to wider developments within the CCG. Some minor amendments were agreed to update the job titles included within the Terms of Reference, and it was agreed that further amendments would be considered following the review process.

Strategies/Policies approved The following policies were approved:

 Access to Infertility Policy – the policy had been updated to provide clarity, and ensure compliance with equality regulations. This is a joint policy which covers the Yorkshire and Humber region.  Children’s Continuing Care Policy – minor amendments.  Medication Policy Guidance – new policy.

Items of positive assurance or items for escalation to the NHS Leeds CCG Governing Body and/or Audit Committee. The Committee requested to highlight the quality visits undertaken with provider organisations, and encourage Governing Body members to take part and inform the quality team if they have suggestions as to which services to visit.

Any other Comments N/A

Agenda Item: GB 19/133 FOI Exempt: No

NHS Leeds CCG Governing Body

Date of meeting: 25th March 2020

Title: The Integrated Quality and Performance Report Lead Governing Body Member: Tick as Katherine Sheerin – Director of System Integration Category of Paper appropriate Helen Lewis – Interim Director of Acute and () Specialised Commissioning Report Author: Mark Fox, Head of Operational Planning and Decision Performance Reviewed by EMT/Date: n/a Discussion  Reviewed by Committee/Date: Quality & Information Performance Committee, 11th March 2020 Checked by Finance (Y/N/N/A - Date): n/a Approved by Lead Governing Body member (Y/N): Yes Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

NHS Leeds CCG Strategic Commitments We will focus resources to: 1. Deliver better outcomes for people’s health and wellbeing  2. Reduce health inequalities across our city  We will work with our partners and the people of Leeds to: 3. Support a greater focus on the wider determinants of health 4. Increase their confidence to manage their own health and wellbeing 5. Achieve better integrated care for the population of Leeds 6. Create the conditions for health and care needs to be addressed around local neighbourhoods Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not  reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability 4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions 7. Failure to enable partners to work together to deliver the CCG commitments 8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY: This report provides assurance to the organisation that we are delivering against the requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described. The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:  NHS Constitution and Operational Planning

The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

NEXT STEPS: The key actions which will be undertaken in relation to performance are as follows:  To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

RECOMMENDATION: The Governing Body is asked to:

(a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the current areas of underperformance and mitigating action.

1. SUMMARY

1.1 This report provides assurance to the organisation that we are delivering against the requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described.

1.2 The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:  NHS Constitution and Operational Planning

1.3 The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

2. SUMMARY OF KEY PERFORMANCE ISSUES

2.1 Primary and Proactive Care  Bowel screening performance is now being achieved on a quarterly basis – increased performance has been contributed to our Leeds Bowel Screening Champion programme.  Cervical Screening performance remains below the national target of 80%. HPV Screening was implemented in Leeds from November 2019 and turnaround times for screening results should reduce significantly over the coming weeks as a result of process changes. The bowel screening champion model is also being further developed to include cervical screening from 2020/21; i.e. the active follow-up of patients.  Breast Screening performance also remains below the national target of 80%. For the reporting period ending Jun-19, coverage equated to 71.2%.  Leeds CCG and Leeds City Council have secured funding for a 3 year locality based screening and awareness programme covering Breast, Cervical and Bowel. The programme will assist in improving upon screening uptake across Leeds and mobilisation has commenced. The funded programme will allow significant investment into increasing screening uptake across the city including targeted work to increase screening uptake in our most deprived parts of Leeds.  The proportion of the population with access to online consultations remains below the national target of 60%. For the reporting period 2019/20 Q3, coverage equated to 38.3%. Further work is ongoing to work with those practices and encourage and support them to complete the process.

2.2 Planned Care and Long Term Conditions  Referral to treatment performance continues to be below 92% with December’s performance was at 87.2%, partly because of a growth in numbers over 18 weeks and partly because of improvements in the total waiting list size overall.  LTHT has a detailed clearance plan and is now progressing with its actions to address waiting times in those specialties where there has been the biggest growth in over 18

week waits (urology, colorectal surgery and gynaecology). This involves some additional clinical capacity internally and the offering choice of alternative providers. It remains the case however that some patients can only be seen within LTHT because of their specialist needs. Whilst achieving significant improvement remains challenging, the rate of improvement has increased.  The growth in total waiting list size since April is in line with our revised trajectory for reduction by the end of March 2020.  The CCG remains behind its original trajectory to eliminate 52 week waits in spinal surgery. Additional clinics and sessions have been established to help manage the numbers of patients ‘tipping’ into the over 52 week bracket and work is ongoing with support from the ‘getting it right first time’ team to ensure all capacity across West Yorkshire and Harrogate is used as well as possible. NHSE are seeking to organise additional tertiary capacity, with a focus on out of WYAAT patients.  In December, 2 week wait performance was achieved at LTHT (with the exception of breast which is below target at 90.2%).  31 day surgery performance in December was 94%% (94.4% at LTHT). Challenges exist in relation to capacity/demand within colorectal, upper GI and urology. Performance month on month is improving but will fluctuate. Actions to address these challenges continue with optimal pathway work underway in these specialties.  62 day performance has stabilised at around 70% for the past 4 months at LTHT.  Similarly, challenges with the same specialties identified above are effecting 62 day referral to treatment performance, reported as 75.6% for December. 62 day screening performance for the same period was 83.3%.

2.3 Unplanned Care  In December 2019, Leeds Teaching Hospitals NHS Trust did not achieve the required 90.6% as per the agreed recovery trajectory (84.3% achieved). Significant operational pressures where experienced in the latter part of December, where Leeds (and nationally) very high paediatric attendances were reported. However January and February to date, the ECS has recovered close to 85%.  Despite performance being below the national standard, LTHT has reported zero 12 hour breaches and zero patients cared for in non-designated areas since May 2018.  The System Resilience Assurance Board manages the work plan and challenges of the unplanned care system. Specific work streams that should indirectly support delivery of A&E 4 hour performance are focused on improving referrals out of the hospital to improve flow relate to community care beds, social care and Neighbourhood teams. A 42% reduction target in super-stranded patients by March 2020 will also improve capacity and support improved performance.  Yorkshire Ambulance Service (YAS) performance for December shows a decrease compared to November with YAS achieving 1 out of 6 response targets (Cat 1). Activity in December was 3.4% over plan in Leeds which was mainly due to Hear Treat and Refer division of the shadow PBR tariff (15.8% over plan).  However, pre- and Post-handover (time taken for YAS staff to handover patients and prepare vehicles, ready to accept new patients) performance failed to meet the 100% target in December.  Whilst targets are under achieving, it is worth noting that Leeds performance is considerably better, compared to other areas within Yorkshire and Humber due to robust systems and processes at both LTHT sites.

2.4 Mental Health and Learning Disabilities  The national standard for IAPT access in 2019/20 is for 22% of the prevalent population to access the service in the reporting year, although we have agreed a lower end of year target with NHS England and a recovering trajectory due to our current position. The current in-year target is 16.8% which is currently below target (YTD).  The new Primary Care Mental Health service, Leeds Mental Wellbeing Service (LMWS), commenced on the 1st November and access performance has improved in recent months due to an increased number of referrals and people entering treatment.  Although the IAPT recovery rate in November was lower than the national standard of 50%, this level of variation from target is within expected limits. Locally sourced data shows the current YTD recovery rate at the end of November to be 48.2% and will continued to be monitored by commissioners.  The CCG mental health commissioning team is currently planning the development of a local action plan for Leeds to improve health checks uptake by people with severe mental illness. This will be reviewed and actioned by the SMI health checks steering group early in 2020. Performance for Q3 2019/20 stands at 50.7% against the target of 60%.  We are not currently achieving the agreed level of patients with a learning disability or autism in hospital for which the CCG is responsible for commissioning their care. Admissions have been increasing due to admissions on the MH inpatient units and in order to achieve our set trajectory for 2019/20, we need to achieve 10 discharges by the end of March 2020. However, in our TCP delivery group has a good degree of confidence that we have sufficient plans to achieve this.  The CCG have developed an incremental quarterly trajectory within the planning submission to meet the performance requirement by the end of Q4 2019/20. Actions to support delivery of this target are detailed in the Learning Disability work plan and require implementation by Primary Care with support and resources provided by the Health Facilitation Team.

2.5 Children’s and Maternity  The target for children waiting no more than 18 weeks for a wheelchair (target 92%) was achieved in Q3 of 2019/20 at 97.6%.  Eating disorder referrals have increased in recent months which has put significant pressures on waiting times where in the last quarter there have been 5 breaches with the longest wait of these breaches at 4.4 weeks from the referral received date.

2.6 Neighbourhood Care  The Leeds Community Healthcare Target for patients achieving their preferred place of death (as recorded on EPACCs) is 85%. This is a key measure which demonstrates the system’s ability to deliver the preferences of patients at the end of life, and in many cases within the LCH caseload to enable them to die safely and comfortably at home.  Performance against this target was 81.5% for 2018/19, but by June 2019 it had slipped to 70.4%. Since that month LCH have made a concerted effort to improve performance and to enable more patients to die in their preferred place of death, and although still

not quite achieving the target, 82.3% of patients achieved their preferred place of death in December. This was the best performance since December 2018.

2.7 Continuing Care  Despite an increased number of referrals prior to the Christmas period the team managed to keep the number of decision support tool (DST) assessments completed in acute settings below 15%.  The number of referrals continues to increase as Continuing Care claims companies advertise, further negative TV coverage and a general overall increased awareness of contributing healthcare also contributes to increase referral numbers. The conversation rate has remained steady at 27%.

3. NEXT STEPS

3.1 The key actions which will be undertaken in relation to performance are as follows:  To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

4. RECOMMENDATION

The Governing Body is asked to:

(a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the current areas of underperformance and mitigating action.

6 The Integrated Quality and Performance Report

Report Period: December 2019

Contents

Indicator Tables NHS Constitution and Operational Planning Measures Page 2-3

Report Key

RAG Rating Note: The RAG rating applied within this report is based upon calculating a limit of 5% higher/lower relative to the expected standard/target. For example, if the expected Standard is a minimum of 92%...

92.5% 'Green' performance would be ≥ 92% 88.0% 'Amber' performance would be 87.4% ≤ x < 92% 85.0% 'Red' performance would be < 87.4%

Performance measures shown to be 'Amber' should still be interpreted as underperforming - a RAG rating has only been applied to serve as a visual guide to understand how close performance is to the expected standard. They should not be interpreted as being currently within a tolerance level.

Interpreting Trends Trend analysis is currently based upon comparing the latest performance with the performance in the previous period. A green arrow represents an improvement in performance An amber arrow represents no change in performance A red arrow represents a deterioration in performance

Sparklines Sparklines have been produced to demonstrate the distance away from the expected target level, with green representing a positive position and red representing underperformance.

The most recent period of data is shown furthest to the right in each sparkline. NHS Constitution and Operational Planning Measures Performance Measures (1 of 2)

Measure Target Data Period Current Trend

NHS Constitution - RTT

RTT - Incomplete Pathway (18 week wait compliance) 92% by Mar-20 Dec-19 87.2%

RTT - Incomplete Pathway (number of patients waiting) 47,411 by Mar-20 Dec-19 45,915

RTT - 52 Week Waits 0 by Mar-20 Dec-19 16

A&E 95% National A&E Waiting Times: % 4 hours or less (LTHT - All Types of A&E) Jan-20 84.3% (93.3% Local by Mar-20) NHS Constitution 99% National Diagnostic Waiting Times Dec-19 99.4% (99.5% Local by Mar-20)

Cancer - 2 Week Wait 93% Dec-19 93.5%

Cancer - 2 Week Wait (Breast) 93% Dec-19 90.2%

Cancer - 31 Day First Treatment 96% Dec-19 97.7%

94% National Cancer - 31 Day Surgery Dec-19 94.4% (94.3% Local by Mar-20) 98% National Cancer - 31 Day Drugs Dec-19 100.0% (98.2% Local by Mar-20)

Cancer - 31 Day Radiotherapy 94% Dec-19 100.0%

85% National Cancer - 62 Day GP Referral Dec-19 75.6% (85.3% Local by Mar-20) 90% National Cancer - 62 Day Screening Dec-19 83.3% (94.4% Local by Mar-20) 90% National Cancer - 62 Day Upgrade Dec-19 77.0% (68.6% Local by Mar-20) Mental Health

Dementia - Estimated Diagnosis Rate 67% Jan-20 75.0%

22% National IAPT Access (12 month equivalent based on rolling 3 months) Nov-19 15.5% (19.0% Local by Mar-20)

IAPT Recovery Rate 50% Nov-19 46.0%

IAPT Waiting Times - 6 Weeks 75% Nov-19 42.7%

IAPT Waiting Times - 18 Weeks 95% Nov-19 98.7%

53% National EIP - Psychosis treated within two weeks of referral Sep-19 81.8% (57.1% Local by Mar-20) People with a severe mental illness receiving a full annual physical health check 60% 2019/20 Q3 50.7% and follow-up interventions (Rolling 12 Months)

Improve access rate to CYPMH (YTD) 32% 2018/19 29.6%

Improve access to CYPMH (Rolling 12 Months) 34% Nov-19 25.5%

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 95% 2019/20 Q3 84.5% Weeks (Rolling 12 Months) Waiting Times for Urgent Referrals to CYP Eating Disorder Services - Within 1 Week 95% 2019/20 Q3 77.8% (Rolling 12 Months)

IAPT Trainees 8 2019/20 Q3 0

Therapists co-located in primary Care 14 2019/20 Q3 12 NHS Constitution and Operational Planning Measures Performance Measures (2 of 2)

Measure Target Period Current Trend

Primary Care Target Period Current

Proportion of the population with access to online consultations 60% 2019/20 Q3 38.3%

Extended Access Appointment Utilisation 75% Nov-19 91.0% Data not Proportion of population that the urgent care system (NHS 111) can directly book 25% currently n/a appointments for in contracted extended access available Learning Disability Target Period Current

Reliance on Inpatient Care for People with LD or Autism - CCGs (All Length of Stays) 17 2019/20 Q3 24

Reliance on Inpatient Care for People with LD or Autism - NHSE (All Length of 14 2019/20 Q3 11 Stays) Other Commitments Number of personal health budgets that have been in place, at any point during 930 2019/20 Q3 1,961 the financial year

Children Waiting no more than 18 Weeks for a Wheelchair 92% 2019/20 Q3 97.6%

Annual Health Checks (AHCs) delivered by GPs for patients on the Learning 2,948 by Mar-19 2019/20 Q2 801 Disability Register (YTD) No more than 56,604 in Total Non-Elective Admissions - +1 LoS Dec-19 41,234 2019/20

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Agenda Item: GB 19/134 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting

Date of meeting: 25 March 2020

Title: Finance Report for the eleven months ended 29th February 2020

Lead Governing Body Member: Visseh Pejhan- Tick as Category of Paper appropriate Sykes, Executive Director of Finance () Report Author: Judith Williams, Head of Corporate Reporting & Strategic Financial Decision Planning Reviewed by EMT/Date: N/A Discussion 

Reviewed by Committee/Date: N/A  Information

Checked by Finance (Y/N/N/A - Date): Y Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives 2. People will live full, active and independent lives 3. People’s quality of life will be improved by access to quality services 4. People will be actively involved in their health and their care 5. People will live in healthy, safe and sustainable communities NHS Leeds CCG Strategic Commitments We will focus resources to: 1. Deliver better outcomes for people’s health and wellbeing 2. Reduce health inequalities across our city We will work with our partners and the people of Leeds to: 3. Support a greater focus on the wider determinants of health 4. Increase their confidence to manage their own health and wellbeing 5. Achieve better integrated care for the population of Leeds 6. Create the conditions for health and care needs to be addressed around local neighbourhoods

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability  4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions 7. Failure to enable partners to work together to deliver the CCG commitments 8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY:

This report provides an update on the financial performance of NHS Leeds Clinical Commissioning Group for the eleven months to 29th February 2020 and the expected outturn position for the 2019-20 financial year.

The CCG is on target to achieve its financial control total of £1.3bn. The QIPP target for 2019- 20 is £26.6m (circa 2% of the allocation). The majority of the QIPP is within contract. However non achievement of the additional capacity wards scheme of £5.5m is now forecast. This is planned to be covered from reserves. QIPP is reported and monitored through the Commissioning for Value Board.

The CCG position is based on the best available information but there are a number of inherent uncertainties which are outside of the CCG’s direct control. These relate to regional/system and national funding allocations, and VAT liabilities. There is also the issue of the financial impact of Covid 19. It is currently assumed that these costs would be met by national allocations.

The forecast across programme areas has decreased by £3.4m in Month 11. This predominantly relates to the release of £2m from the prescribing forecast in relation to anticipated cost pressures that are not now expected to crystallise. And a further £1.3m reduction in the acute forecast linked to the allocation from NHSE for overseas visitors.

NEXT STEPS:

Updates on the 2019-20 financial position will continue to be presented to the Governing Body and/or Executive Management Team (EMT) on alternate months to ensure that the CCGs’ financial position is formally reported and reviewed each month under the CCGs’ governance arrangements.

RECOMMENDATION:

The Governing Body is asked to:

(a) Consider the Month 11 financial position; and (b) Discuss, comment and highlight actions required to progress and report to the next meeting of the Executive Management Team.

2 NHS Leeds Clinical Commissioning Group Finance Report for the Eleven Months ended 29th February 2020

Page 1 Financial Performance Report 29th February 2020 At 29th February NHS Leeds Clinical Commissioning Group 2020 At Year End 2018-19 RAG RAG

CCG Expenditure does not exceed planned level GREEN GREEN Programme spend less than allocation GREEN GREEN Running costs spend less than allocation GREEN GREEN Delegated Co-commissioning less than allocation GREEN GREEN Planned Surplus in year GREEN GREEN QIPP RED RED Clear identification of risks against financial delivery & mitigations GREEN GREEN Delivery of Mental Health Investment Standard GREEN GREEN Better Payment Practice Code - to pay 95% of valid invoices by due date or within 30 days of receipt of a valid invoice, GREEN GREEN Cash at bank balance within 1.25% of the monthly amount requested or £250k, whichever is greater GREEN GREEN

Page 2 Overview 29th February 2020

The CCG is on target to achieve its financial control total of £1.3bn. The QIPP target for 2019-20 is £26.6m (circa 2% of the allocation). The majority of the QIPP is within contract. However non achievement of the additional capacity wards scheme of £5.5m is now forecast. This is planned to be covered from reserves. QIPP is reported and monitored through the Commissioning for Value Board.

Page 3 Financial Position Summary 29th February 2020

Annual Variance NHS Leeds Clinical Commissioning Group Year To Date Annual movement from Revenue Expenditure 2018-19 Budget Actual Variance Budget Forecast Variance previous month £'000 £'000 £'000 £'000 £'000 £'000 £'000 Programme Services Acute Services 603,229 604,281 1,052 655,427 656,736 1,309 -1,376 Mental Health Services 144,027 145,019 992 157,700 159,273 1,572 10 Community Health Services including Childrens Services 135,806 135,057 -749 147,704 147,194 -511 -137 Continuing Care Services 51,037 52,092 1,055 55,675 56,998 1,323 149 Prescribing and Primary Care Services 143,783 141,020 -2,764 156,842 154,063 -2,779 -2,117 Other 3,300 3,451 151 5,905 4,911 -994 83 Primary Care Co-Commissioning 108,548 108,548 0 118,234 118,234 0 0

Total Programme Services 1,189,730 1,189,468 -262 1,297,488 1,297,408 -80 -3,388

RUNNING COSTS 12,725 11,997 -729 15,320 13,385 -1,935 16

RESERVES 0 991 991 2,046 4,061 2,015 3,372

CCG Net Expenditure 1,202,455 1,202,455 0 1,314,854 1,314,854 0 0

Page 4 Allocations 29th February 2020

NHS Leeds Clinical Commissioning Group Co- IN YEAR Programme Running Costs Allocations 2018-19 commissioning ALLOCATION £'000 £'000 £'000 £'000 Opening Baseline Allocation 1,158,814 17,436 116,424 1,292,674 Subtotal Month 1 Adjustments 0 0 0 0 Subtotal Month 2 Adjustments 0 0 0 0 Subtotal Month 3 Adjustments 6,464 0 0 6,464 Subtotal Month 4 Adjustments 85 0 0 85 Subtotal Month 5 Adjustments 24 0 0 24 Subtotal Month 6 Adjustments 876 0 0 876 Subtotal Month 7 Adjustments 2,010 0 0 2,010 Subtotal Month 8 Adjustments 6,432 0 4 6,436 Subtotal Month 9 Adjustments 2,647 0 0 2,647 Subtotal Month 10 Adjustments 278 744 0 1,022 Subtotal Month 11 Adjustments 2,616 0 0 2,616 Closing Allocation 1,180,246 18,180 116,428 1,314,854

Month 11 allocations Non recurrent Programme allocations received in month are: £475k for FTA funding Q2 , £15k 26 Weeks Pilot funding 2019/20 , £26k Digital First primary care Funding 19/20, £80k Obstetric medicine training, £73k Pharmacy Integration MOCH - Q4, £29k LTBI Q4, £1,509k 2018-19 Policy premium tranche 1, £92k Mental Health Problem Gambling, £180k AKI Funding 19/20 - Road Testing Adoption Fund and £137k Clinical Waste pass through funding for LYPFT AND LTHT

Page 5 Risks and Mitigations 29th February 2020

NHS Leeds Clinical Commissioning Group Risks and Mitigations Risk Area Full Risk Value Description of Risk £'000 Reflects risks inherent in contract envelopes set currently, resilience pressures in the system and non achievement of QIPP targets Acute Services 0

Transforming Care Partnership (TCP) and MH S117 risks Mental Health 0

Risk of additional childrens ventilation packages Community Health 0 Risks of additional capacity needed beyond planned and contracted levels Continuing Care 0 Demand and pricing pressures (prescribing), Category M price changes Primary Care 0 Primary Care Co Commissioning 0 Live legal challenges Other 0 Running Costs 0 Total Risks 0 Full Mitigation Description of Mitigation £'000 Contingency held 0 General Reserves held 0 Total Mitigation 0 Net Risk 0

Material risks are presumed to have crystallised by this point in the year, and general reserves and the contingency have been played into budgets and forecast.

Page 6 Acute Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Leeds Teaching Hospitals NHS Trust (LTHT) 407,955 407,955 0 445,115 445,115 0 Mid Yorkshire NHS Trust 25,978 25,978 0 28,339 28,339 0 Harrogate Foundation Trust 25,942 26,187 245 28,301 28,568 267 Bradford Foundation Trust 5,215 4,519 -696 5,689 4,930 -759 York Foundation Trust 2,527 2,072 -455 2,757 2,261 -496 Other NHS Trusts 35,725 37,211 1,487 36,265 37,917 1,652 Non contract Activity (NCAs) 6,443 8,177 1,733 7,029 8,920 1,891 Non NHS Acute 46,793 46,204 -589 51,047 50,404 -643 Unplanned Care 46,651 45,978 -673 50,886 50,283 -603 Total Acute Services 603,229 604,281 1,052 655,427 656,736 1,309

The Acute and Planned Care directorates are forecasting an overtrade position of £1,309k in AP11. This is an improvement of £1,376k from the previous month.

The main reason for the movement is a reduction in the overseas visitors forecast of £1.4m. This is due to the allocation being partly retrospective, covering the outturn from the previous year as well as this years forecast. The costs of overseas visitors increased in the middle of last year, after the submission was made, and has continued in this financial year. Large under trades continue at Nuffield (£1.8m) and Yorkshire Clinic (£0.8m). Conversely, the AQP's, despite a reduction of £0.2m this month, continue to overtrade, by £2.6m.

There are no significant changes to the Unplanned Care Forecast. 111, GP Out of Hour and Urgent Treatment Centre activity is increasing in line with COVID 19 concerns. The CCG is working closely with providers and the wider system on this, and the immediate financial risk is assumed to be covered by the potential for central funding to support this. This will continue to be reviewed.

Page 7 Mental Health Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Leeds and York Partnership Foundation Trust (LYPFT) 98,054 98,698 645 106,968 107,616 649 Tees Esk and Wear Valley NHS Foundation Trust (TEWV) 1,036 987 -49 1,130 1,130 0 Bradford District Care NHS Foundation Trust 149 136 -14 163 148 -15 Independent/Voluntary Sector/LCC/Other NHS 5,727 4,649 -1,078 6,231 5,095 -1,135 Learning Disabilities 25,025 26,233 1,209 27,300 29,131 1,832 IAPT 6,566 6,396 -171 7,774 7,511 -263 Mental Health Specialist Services 6,186 6,566 380 6,749 7,165 416 Mental Health Non Contract Activity (NCA) 481 589 108 525 640 115 Mental Health Other 802 765 -37 861 834 -27 Total Mental Health Services 144,027 145,019 992 157,700 159,273 1,572

Mental Health NHS contracts: Leeds and York Partnership Foundation Trust (LYPFT) now forecast to overspend by £649k as non-recurrent support has been agreed for 19/20. Independent/Voluntary Sector/LCC/Other NHS: Forecast underspend of £1.1m relates to slippage on transformation budget and other 19/20 developments

Learning Disabilities: the forecast overspend has increased by 0.1m to £1.8m. This is based on revised forecasts from Leeds City Council (LCC) who commission this service. Mental Health Specialist Services (which includes the Transforming Care Partnership (TCP), and elective funding, and Section 117): S117 overspend, due to ongoing high cost service users, has reduced by £456k this month due to additional non recurring allocation from NHS England. Continues to be partially offset by specialist expenditure where there has been a delay in the step down of patients from specialist commissioning. IAPT Services: Forecast to underspend based on the new provider contract following the IAPT reprocurement.

Mental Health NCAs: Forecast overspend reduced by £65k based on current activity. The main risk to this forecast continues to be the Transforming Care Programme and specialist patients with complex needs, requiring high cost and different services to those currently provided by the LD pooled budget and LYPFT, meaning that additional bespoke services have to be commissioned, often out of area.

Page 8 Community Health Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Leeds Community Healthcare NHS Trust (LCH) 94,900 94,700 -200 103,621 103,680 58 Community Reserves 651 340 -311 710 404 -306 Voluntary Sector/Local Authority (LA) 18,122 18,088 -34 19,769 19,661 -109 Community Beds 10,766 10,698 -68 11,745 11,675 -70 Hospices 5,952 5,957 5 5,974 5,969 -4 Reablement 2,587 2,573 -14 2,822 2,807 -15 Safeguarding 722 660 -61 787 738 -49 Sub Total Community Health Services 133,699 133,016 -683 145,428 144,933 -495 Children's Services excluding Continuing Care 2,107 2,041 -66 2,277 2,261 -16 Total Community Health Services including Childrens 135,806 135,057 -749 147,704 147,194 -511

LCH and Community Reserves: The net underspend of £248k is due to slippage in 19/20 service developments, this has increased by £75k from previous month with additional slippage on new developments that were hoping to be in place by the end of 19/20 but have been delayed until 20/21

Voluntary Sector/Local Authority: underspend due to anticipated slippage on several BCF schemes.

Page 9 Continuing Care Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Continuing Healthcare (CHC) 26,370 26,989 620 28,767 29,510 743 Continuing Healthcare Personal Health Budgets (PHBs) 12,376 11,876 -500 13,501 12,983 -518 Funded Nursing Care (FNC) 6,694 7,291 597 7,303 7,959 656 Children Continuing Care including PHBs 1,311 1,211 -99 1,430 1,313 -117 Continuing Healthcare - operational 2,281 2,186 -96 2,488 2,408 -79 Neuro-rehab 2,005 2,538 534 2,187 2,823 636 Total Continuing Care Services 51,037 52,092 1,055 55,675 56,998 1,323

Continuing Healthcare, including PHBs: spend across these 2 lines should be looked at in conjunction as there is a continual switch between the two as PHB packages become the default delivery model for CHC. Forecast has increased from the previous month by £257k to a £226k overspend because of additional demand on the service. Funded Nursing Care: From 1st April 2019 the rate for FNC increased from £158.16 p/w to £165.56 p/w of which the annual impact within the forecast is £350k. Forecast is similar level to last month. Children Continuing Care including PHBs: Forecast underspend as there are not expected to be any new ventilation packages with significant costs that will impact this financial year.

Continuing Healthcare - operational: Underspend on staffing costs due to vacancies within the team.

Neuro Rehab: There are continuing long term high cost patients leading to a forecast overspend. The patients within this cohort are regularly reviewed by the clinical team to ensure the forecast is as up to date as possible but these are complex low volume high cost patients so are very sensitive to fluctuations. Forecast is similar level to last month.

Page 10 Prescribing and Primary Care Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Prescribing 111,881 109,589 -2,292 122,052 119,740 -2,312 Ex centrally funded drugs 3,130 3,439 309 3,414 3,750 336 Oxygen contract 1,139 1,180 40 1,243 1,283 40 Primary Care Schemes 20,027 20,122 95 21,836 21,954 118 Clinical Leads 425 454 29 464 495 31 Primary Care - GP Information Technology (GP IT) 3,038 2,491 -548 3,314 2,706 -608 Out Of Hours 119 60 -60 130 66 -64 Medicines Optimisation NHSE Non Recurring Funded Projects 681 680 -1 743 766 23 Sub Total Prescribing and Primary Care Services 140,441 138,013 -2,428 153,196 150,761 -2,436 Prescribing Staff 1,533 1,444 -89 1,672 1,575 -97 Primary Care Staff 706 672 -34 770 740 -30 Confederation Staff and Delivery Costs 1,103 890 -213 1,204 988 -215 Sub Total GP Confederation 3,342 3,007 -336 3,646 3,303 -343 Total Prescribing & Primary Care Services 143,783 141,020 -2,764 156,842 154,063 -2,779

Prescribing (inc centrally funded drugs and out of hours): December 19 data has now been received. The BSA forecast has increased by £520k compared to previous month, but with various adjustments such as the Freed Up Resources (FURs) scheme, the overall change in Prescribing compared to last month is a £253k increase. Overall the forecast remains within budgeted levels with 9 months of data received, and with no further pressures anticipated over budget, this has resulted in the release of £2m which was previously reserved for anticipated cost pressures which are now not expected to materialise. All Practices’ Freed Up Resources for 2018/19 have been paid and the process is now complete. Primary Care: Overall in Primary Care Schemes there is an overspend of £118k. Proactive Care is overspent by £34k due to the utilisation of slippage from various contracts towards non recurrent funds for agreed projects. The remainder of the £78k overspend is due to agreed further specialist support within General Practice. GP IT: Forecast underspend of £608k due to delays in implementation of software / IT schemes such as office 365 Staffing: Staffing forecast underspends relates to vacancies, clinical leads overspend relates to savings target non achievement. GP Confederation: note there are other funding streams within the main primary care services lines, such as extended access, which are also part of the funding flows through the confederation. Underspend here relates to in year slippage on non recurrent schemes, such as wound care,which will now continue into next year.

Page 11 Other Services 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Sustainability and transformation programmes 1,487 1,753 266 3,790 2,899 -891 System wide support and workforce transformation 1,288 1,345 57 1,542 1,613 71 Cancer Projects 0 0 0 0 0 0 Programme Staff - Transforming care/out of area 187 183 -4 204 205 1 Programme Staff - Nursing and Quality 338 170 -168 369 193 -175 Quality Premium Programme 0 0 0 0 0 0 Total Other Services 3,300 3,451 151 5,905 4,911 -994

Underspend on transformation programmes relates to underspend on planned programme, but note that this underspend is offset by an element of spend on organisational development work which is transformational but relates to running costs, and so is forecast within admin budgets. Overspend on system wide support relates to property services void costs (£66k) offset by small underspends on various projects. Underspend on Nursing and Quality relates to vacancies being held.

Page 12 Primary Care Co-Commissioning 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 GMS 25,912 26,574 662 28,267 28,267 0 PMS 47,321 46,081 -1,240 51,644 51,644 0 APMS 6,899 6,310 -589 7,550 7,650 100 Premises cost reimbursements 13,952 13,934 -18 15,087 15,017 -70 Other premises costs 733 818 85 751 821 70 Enhanced Services 2,541 2,658 117 2,786 2,786 0 QOF 8,954 9,238 284 9,768 9,768 0 Other GP Services(inc PCO) 2,236 2,934 699 2,380 2,280 -100 Reserves 0 0 0 0 0 0 Total Primary Care Co-Commissioning 108,548 108,548 0 118,234 118,234 0

Co-Commissioning expected spend is anticipated to remain in line with budgets. The Primary Care Network payments continue in line with the new five year framework for GP Services and the NHS long term plan.

Page 13 Running Costs 29th February 2020

Year To Date Annual NHS Leeds Clinical Commissioning Group Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Pay 9,729 9,347 -381 10,535 10,190 -344 Non Pay/Income 2,997 2,649 -347 4,785 3,195 -1,591 Total Running Costs 12,725 11,997 -729 15,320 13,385 -1,935

Running costs are now expected to underspend by £1,935k due to vacancies during the year and non pay non recurring underspends. Any in year underspend will be released for use in Programme Services.

Page 14 Consolidated Statement of Financial Position 29th February 2020 29th February 31st March 2020 2019 £'000 £'000 Current Assets Trade & Other Receivables 10,903 6,426 Cash & Cash Equivalents 0 122 Total Current Assets 10,903 6,548 Total Assets 10,903 6,548

Current Liabilities Trade & Other Payables: (60,538) (58,179) Borrowings (468) 0 Provisions (388) (3,415) Total Current Liabilities (61,394) (61,594)

Total Assets less Current Liabilities (50,491) (55,046) Non-current Liabilities Provisions (5,343) (1,386) Total Non-current Liabilities (5,343) (1,386)

Total Assets Employed (55,834) (56,432) Financed by Taxpayers’ Equity General Fund (55,834) (56,432) Total Taxpayers’ Equity (55,834) (56,432)

Page 15

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Agenda Item: GB 19/135 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting

Date of meeting: 25th March 2020

Title: Chief Executive Officer’s Report

Lead Governing Body Member: Tim Ryley, Chief Tick as Category of Paper appropriate Executive () Report Author: Various Decision

Reviewed by EMT/Date: N/A Discussion

Reviewed by Committee/Date: N/A  Information

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability 4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions 7. Failure to enable partners to work together to deliver the CCG commitments 8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY:

Coronavirus – Covid 19 Update The CCG continues to coordinate the system response to Covid 19 in conjunction with local authority partners. There has been excellent partnership working across the System on this, as we have worked on the containment phase of this operation over the past few weeks. The situation is obviously rapidly changing, and we remain focused on ensuring the best possible outcomes for our population at this very difficult time.

Sustainability Report for the NHS Leeds CCG

NHS Leeds CCG and its predecessors have an excellent record of developing and delivering plans to reduce our carbon footprint in response to climate change. Over recent years our plans and energy/waste reporting have regularly received the highest rating from the NHS Sustainability Development Unit.

However the increasing focus on climate change nationally and locally requires us to relook at our plans, with an increased focus on maximising our potential impact on addressing climate change as an anchor organisation within the Leeds and wider West Yorkshire and Harrogate system. The CCG takes an active role in a range of city-wide climate change planning and delivery groups and, alongside other partners in Leeds, has signed up to the Leeds Health and Care Climate Commitment.

The Leeds Health and Care Climate Commitment

The CCG has established its own internal Climate Change Group that is leading on the refresh of the CCG’s Green Plan (previously known as Sustainability Management Development Plan) with support from Walker Resource Management (WRM is a specialist climate change consultancy that has supported the CCG and other systems partners over a number of years).

The proposed areas of focus for the plan are: i) Reducing WIRA House Carbon Impact: WRM have undertaken a review of the current position in relation to options for reducing the CCG’s carbon impact at Wira House. The findings are generally positive with limited scope for significant further impact. A number of actions have been identified that are currently being taken forward. ii) Improving Carbon Literacy of Staff: Improving staff understanding of actions that they can take at work and home to reduce their carbon footprint. Primary options include: inclusion of briefing in staff induction; updates in general team briefings alongside engagement of specialist carbon literacy providers to run a tailored programme. iii) Transport and Travel: Review of options to minimise staff transport and travel including: increased working from home (where that can be facilitated appropriately); improving access to and uptake of technology for non-face to face meetings; incentivising green travel to work;, exploration of options for encouraging electric vehicle use through the lease scheme and; use of community-based local meeting spaces. iv) Commissioning for Sustainability: Building a sustainability dimension into commissioning and procurement processes i.e. adding in consideration of how commissioning decisions impact on environmental, social and economic value. v) Partnership Working: Identifying key areas where the CCG can work with others to support the delivery of citywide ambitions. Examples may include: supporting reductions in face to face health and care provision through technology; increasing availability of electric charging points; sharing resources (working closer to home in shared facilities); adoption of common technology solutions; the CCG’s role in public education and awareness.

Over the next two months we will aim to complete the update of our plans with a draft being available in April/May and would ask the Governing Body to endorse the CCG’s sign-up to the Leeds Health and Care Climate Commitment.

2020/21 Contract Development Work has been ongoing with all NHS partners on developing our contracts for 2020/21 in line with national timetables and in ensuring that we are aligned on all our various planning submissions both within Leeds and across the ICS.

Business case for the Assessment and Treatment Unit Model for the ICS Work is progressing on the business case for the Assessment and Treatment Unit model for the ICS (admissions for people requiring acute admissions for a Learning Disability). There was a presentation to Joint Overview and Scrutiny Committee around the business case and engagement plan. We continue to work through the financial assumptions with CCG and provider colleagues to ensure we have a viable agreed model. The preferred model would see Leeds patients travelling to Bradford or Wakefield where the facilities are co-located with acute sites.

LD Transforming care Programme Dischard Trajectories We continue to make good progress on this. The target is for Leeds reach 13 (7 discharges planned for March), therefore, we are forecasting that we will reach 16, which is really good progress considering Leeds TCP was significantly behind its trajectory 12 months ago.

IAPT update The consortium is on track in terms of mobilisation of the new model and the formal launch of the new service model is planned for April. The CCG has agreed and have resourced the service to deliver 22% access trajectory for 2020/21.

Communications and Engagement Update The report for communications and engagement activity during November and December is attached within the supporting documents and is published here: https://www.leedsccg.nhs.uk/publications/communications-and-engagement-report-january-to- february-2020/ Governing Body members are asked to receive this information as assurance that the CCG is delivering its statutory duties to ensure public involvement and consultation. Some key highlights include:

 Maternity and neonatal services – the formal consultation on two viable options for maternity and neonatal care, as part of Leeds Teaching Hospitals NHS Trust (LTHT) Building the Leeds Way project, began on 13 January and will close on 6 April. Over the last few years, the CCG has worked with LTHT and NHS England specialised commissioning team, and undertook ongoing engagement with mums and their families to help shape the plans. Full details about the consultation can be found here https://www.leedsccg.nhs.uk/get-involved/your-views/maternityleeds/

 Patient Assurance Group (PAG) –the Governing Body Lay Member for Patient and Public Involvement chaired a meeting of the PAG in February. It was attended by patient volunteers, Healthwatch and Voluntary Action Leeds representatives, and CCG staff. Members received a presentation and engagement plans for the developing cardiac and pulmonary rehabilitation programmes. The PAG was assured by the plans and the minutes are published on the CCG website.

 Temperature-triggered bus shelter ad campaign – we launched this digital advertising campaign to remind people of the dangers posed by lower temperatures. When the temperature is between 1c-8c, the adverts alert people with asthma that colder weather can have an effect on their health and to carry their inhaler with them at all times as they could need it at any given point.

 Covid-19 – along with colleagues at Leeds City Council, the team is leading on the city’s communication plan for Covid-19 and has been working closely with colleagues across the local, regional and national healthcare system to communicate with the public, staff and primary care.

 Social and online media – our website page views increased by 56% to 22253 during January and by a further 2% to 23267 during February. On Twitter, February’s most popular content was a post promoting a drop-in session for the maternity consultation at the Hamara Centre. The post received 10 retweets and 6 likes. It managed to be seen an impressive 10,272 times, and many were converted into website visitors who clicked through the link to find out more.

Increasing diversity in our leadership

NHS Leeds CCG has joined its partners in the West Yorkshire and Harrogate (WY&H) Health and Care Partnership in making a commitment to work to increase the diversity of leadership across our organisations.

Our workforce is more diverse than it has been any other time previously; unfortunately, across some levels of our organisations particularly in leadership positions, our workforce does not reflect our population. There is considerable evidence which suggests tackling workforce race and equality improves staff experience, organisational efficiency and most importantly improves the outcomes for the people using those services.

In our latest Workforce Race Equality Standard (WRES) report in 2019 the CCG reported that (using the definitions of the WRES technical guidance) we had 14.5% Black, Asian and Minority Ethnic (BAME) staff, which almost mirrored the BAME population of Leeds (14.9% according to the Census 2011).

However, the percentage of BAME staff at Band 7 and above was 11.6% and 0% of our Governing Body members are BAME (using the WRES definition).

Research undertaken by the NHS England workforce race equality team has identified that one of the main factors believed to affect patient satisfaction is the experience of staff. This research also demonstrated the extent to which an organisation values its minority staff is a good barometer of how well patients are likely to feel cared for.

The WY&H partnership has been working with chairs of BME networks across the system on a plan towards the Partnership’s vision of fairness and equality for all. This has included recommendations on how to progress this agenda both across the system and within individual organisations.

RECOMMENDATION:

The Governing Body is asked to:

(a) Receive the Chief Executive’s report (b) Receive the communications and engagement update as assurance that the CCG is delivering its statutory duties to ensure public involvement and consultation

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Agenda Item: GB 19/136 FOI Exempt: No

NHS Leeds CCG Governing Body

Date of meeting: 25 March 2020

Title: National Staff Survey 2019

Lead Governing Body Member: Sabrina Tick as Armstrong, Director of Organisational Category of Paper appropriate Effectiveness () Report Authors: John Scott, Head of People & Decision OD Reviewed by EMT/Date: 8 January 2020 Discussion Reviewed by Committee/Date: Workforce & Information  Diversity Group (28 January 2020) Checked by Finance (Y/N/N/A - Date): N/A Approved by Lead Governing Body member (Y/N): Yes Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives  2. People will live full, active and independent lives  3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care  5. People will live in healthy, safe and sustainable communities 

EXECUTIVE SUMMARY:

The CCG took part in the national NHS Staff Survey (NSS) during October and November last year. This is the first time the merged CCG has been involved. The response rate was very good (79%) and we now have access to the outcomes and reports.

The response is broadly positive, though there are areas for improvement. Best practice for CCGs is to concentrate their analysis on comparison with previous years and embed any action planning within their staff engagement plans. Leeds CCG intends to follow that advice.

Full details of the staff survey can be found in the supporting information documents.

NEXT STEPS:

The survey has been published, shared with staff and engagement activity has begun. This is detailed in the paper and Annex D.

RECOMMENDATION:

The Governing Body is asked to:

a) Consider this paper and its attachment; b) Reflect on the broadly positive response; and c) Agree the planned activity to embed this information into our broader plans for staff engagement.

1. SUMMARY

1.1 The CCG took part in the national NHS Staff Survey (NSS) during October and November last year with a good response rate of 79%. We now have access to the outcomes and reports and, whilst the response is broadly positive, there are areas for improvement. Best practice for CCGs is to concentrate their analysis on comparison with previous years and embed any action planning within their staff engagement plans. Leeds CCG intends to follow that advice.

2. BACKGROUND

2.1 The CCG took part in the national NHS Staff Survey (NSS) during October and November last year. This is the first time the merged CCG has been involved. The response rate was very good (79%) and reflected the national level for CCGs (80%). We engaged Picker as our survey partner who have provided a comprehensive suite of reports based on our results. This includes comparative data to other CCGs and other NHS organisations.

2.2 Whilst interesting, this is of limited practical use for us – few CCGs offer a similar size or location, and local organisations have as many differences as similarities. Best practice for CCGs is to focus on year-on-year trends which, unfortunately, is not available to us. This report (attached at Annex A within the supporting information) therefore offers a baseline against which we can track improvements and any slippage.

2.3 The reports also offer sub-sets of the data in terms of directorates, work groups and demographics. That said, it is noteworthy that the staff response is broadly consistent across the CCG. The situation is further complicated by the date of the survey data, which was drawn on 1 September 2019 and so pre-dated the recent reallocation of Director portfolios. It may therefore be more informative to look at work groups which, again, show a broad consistency across the organisation.

2.4 The management summary is therefore attached within the supporting information documents for your consideration. For those of you unfamiliar with NSS reporting, you may be surprised at the volume of information (and this is only one of several documents). You will also see that the NSS reports only where there are 11 or more responses to questions. This is to protect individual confidentiality but also makes it difficult to identify specific groups of staff.

Organisational highlights

2.5 The response rate is high (slide 4 of the deck) and so this can be seen as a representative and robust view from staff at the CCG. 80% is more than double the penetration achieved by the last similar exercise (the Temperature Check conducted during summer 2018).

2.6 The headline message is that the survey describes an organisation that, overall, is working well and is broadly content with working conditions. This is illustrated by the five ‘best’ results in comparison to other CCGs (slide 5) which shows strong results in the key areas of learning and development, appraisal, resourcing and flexible working. There are

similarly good results on trust, clarity of role and initiative (slide 15); and for recognition, respect and responsibility (slide 16). And whilst there may be work to do concerning organisational value, time pressures and relationships at work (slide 17), these would appear to be in line with national responses.

2.7 The assessment of line managers is broadly positive, in some contrast to that of senior managers (slides 18 and 19). The results for Health and Wellbeing are more mixed and would also benefit from further investigation (slides 20, 21 and 22). There are similar inconsistencies around the effectiveness of appraisal, though the process does seem to be working well in terms of learning and development (slide 23).

2.8 The Governing Body will also want to reflect on the External Benchmarks (slides 26 to 38). There are also further demographic breakdowns by age, ethnic origin, gender, disability and age (at Annex B) and for staff groups (at Annex C).

3. PROPOSAL

3.1 The survey results are the start of the conversation, not the end. Strong advice is that effective responses to NSS surveys are based on better understanding any obvious issues but setting medium and long term improvement plans embedded into wider staff engagement activity.

3.2 We therefore need a plan to a response that acknowledges the messages contained in the reports but also builds on our existing work to engage with our people (like the Staff e- Bulletin, Team Briefs, Staff Conferences and our distributed leadership model.)

3.3 There are particular areas that need further targeted investigation. For example, it would make sense to ask the Health and Wellbeing Group to consider the wellbeing results which clearly show that our staff believe more could be done. We will also ask the recently-formed BAME (Black Asian and Minority Ethnic) group to discuss and make recommendations on the demographic outcomes.

3.4 Similarly, there are practical steps that the EMT could take to address the issues of visibility and profile. We will also arrange a couple of staff drop-in sessions towards the end of March where staff can discuss any aspects of the survey.

4. NEXT STEPS

4.1 Individual Directors will want to discuss their results with their management teams and in wider groups, notwithstanding the care required around using data that is not absolutely current in all cases. We will also want to continue to use our Senior Leadership Tier as a conduit for information. This, unhelpfully, may increase the staff opinion that our senior people are not known.

4.2 We are also currently deep into consultation on Shaping Our Future and it makes little sense in creating a separate set of discussions. Once the future operating model is agreed, the focus will be on providing the required OD support. The next iteration of the model will be shared on 23 April at the next Staff Conference and we will prepare material to place the survey outcomes alongside that.

4.3 Finally, we expect the publication of the NHS People Plan in late March/early April which will require us to review our people arrangements and develop, if necessary, our own version of the ‘People Promise’. We will want to align our response to the survey within that context also.

5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 None identified.

6. FINANCIAL IMPLICATIONS AND RISK

6.1 We engage one of the recommended NHS Survey partners, Picker International, to conduct the survey on our behalf. The cost is £3.5k over the three year contract.

7. COMMUNICATIONS AND INVOLVEMENT

7.1 Based on all the interactions described in section 4 above, we will develop a ‘you said, we did’ campaign to address some of the common issues, including some frequently mentioned in the free text written comments like car parking, hot-desking and resources. Annex D summarises the proposed engagement plan.

8. WORKFORCE

8.1 No additional workforce issues.

9. EQUALITY IMPACT ASSESSMENT

9.1 Survey is conducted by a recommended partner. Consideration of their EIA was included in our tender and procurement arrangements.

10. ENVIRONMENTAL

10.1 None identified.

11. RECOMMENDATION

The Governing Body is asked to:

a) Consider this paper and its attachments; b) Reflect on the broadly positive response; and c) Agree the planned activity to embed this information into our broader plans for staff engagement.

5 Annex D: ENGAGEMENT SUMMARY

Aim: To embed Staff Survey discussions with work on People Plan and Shaping Our Future

February

 NSS 19 Published.  Page created on CCG Extranet.  Discussion at EMT. March

 Director discussions with management teams begin  Governing Body discussion  Drop-in sessions  Staff messages in e-Bulletin  Discussions begin at BAME network  Discussions begin at H&W Group April

 Expected launch of NHS People Plan and People Promise  Staff Conference  Discussions continue in Directorates  Develop ‘you said, we did’  Further discussion at EMT May

 Develop local People Promise  OD activity begins in support of Shaping Our Future June

 Launch ‘You said, we did’ September

 Begin briefings for NSS20 October/November

 NSS20 Fieldwork  Staff Conference (prov)

Agenda Item: GB 19/137 FOI Exempt: No

NHS Leeds CCG Governing Body

Date of meeting: 25 March 2020

Title: Primary Care Rebate Policy

Lead Governing Body Member: Katherine Tick as Category of Paper appropriate Sheerin, Director of System Integration () Report Author: Keegan Hutchinson, Specialist Medicines Commissioning Technician Decision  Kim Mooring, Senior Commissioning Technician Reviewed by EMT/Date: N/A Discussion

Reviewed by Committee/Date: Quality & Information Performance Committee - 15/01/2020 Checked by Finance (Y/N/N/A - Date): N/A Approved by Lead Governing Body member (Y/N): Y Leeds Health & Wellbeing Strategy Outcomes – that this report relates to: 1. People will live longer and have healthier lives 2. People will live full, active and independent lives 3. People’s quality of life will be improved by access to quality services  4. People will be actively involved in their health and their care 5. People will live in healthy, safe and sustainable communities NHS Leeds CCG Strategic Commitments We will focus resources to: 1. Deliver better outcomes for people’s health and wellbeing  2. Reduce health inequalities across our city  We will work with our partners and the people of Leeds to: 3. Support a greater focus on the wider determinants of health  4. Increase their confidence to manage their own health and wellbeing 5. Achieve better integrated care for the population of Leeds  6. Create the conditions for health and care needs to be addressed around local neighbourhoods

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge 2. Failure to assure the delivery of high quality services, leading to commissioned services not  reflecting best practice and improving care 3. Failure to achieve financial stability and sustainability 4. Lack of provider and clinical support for change will impact on the development and  implementation of the CCG strategy 5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas 6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions 7. Failure to enable partners to work together to deliver the CCG commitments  8. Failure of system to be adaptable and resilient in the event of a significant event

EXECUTIVE SUMMARY: The Department of Health and Social Care (representing the UK Government, and the governments of Scotland, Wales and Northern Ireland), NHS England and the Association of the British Pharmaceutical Industry recognise the importance of collaboration between the public and private sectors in delivering improved health gains from medicines in the national health service across the United Kingdom (NHS), and in supporting the pharmaceutical industry in the United Kingdom so that it can continue to innovate now and in the future.

A number of manufacturers have established ‘rebate schemes’ for drugs used in primary care to support the NHS Quality, Innovation, Productivity and Prevention (QIPP) agenda. The NHS is charged the Drug Tariff price for primary care prescriptions dispensed; then those manufacturers providing a rebate to the primary care organisation agree a discount which is then verified using ePACT data.

Primary care rebate schemes (PCRS) are contractual arrangements offered by pharmaceutical companies, or third party companies, which offer financial rebates on GP prescribing expenditure for particular branded medication. These schemes usually reimburse organisations retrospectively with an agreed percentage discount of the total amount of a particular branded medication prescribed and dispensed. PCRS, underpinned by robust assessment and governance procedures, can lead to significant cost savings.

The rebate policy has been updated as some aspects were out-of-date. We have changed the way we review rebates to ensure a robust governance procedure is in place to maximise benefit without affecting quality or safety. There are two pathways for reviewing a rebate dependent on whether or not PrescQIPP has reviewed the medicine. The PISGRB has been created by PrescQIPP in response to requests by commissioners to provide guidance as to the acceptability of Primary Care Rebate Schemes being offered to the NHS by the pharmaceutical industry. The role of the PISGRB is only to provide an independent assessment of any particular scheme. The template has changed to show the different essential teams that will be involved in the decision making in assessment stage 2, before an agreement has been made with the relevant prompts from each team. The relevant teams have been involved in updating this policy as highlighted in assessment stage 2 where each team added their own questions / prompts that they would answer when they are reviewing a rebate scheme.

The updated policy has been reviewed by the Commissioning Of Medicines Group (COMG) on 13/11/2019. The Quality & Performance Committee recommended the Governing Body approve the policy on 15.01.20, in principle, with the amendments of the wording in the policy to “reviewed by COMG” instead of “approved” as COMG are not approving individual rebate schemes but reviewing with secondary care providers to ensure there are no adverse effects on secondary care.

The full policy is available within the supporting information documents.

The Governing Body is asked to approve the updated policy for use in Primary Care.

NEXT STEPS:

Approving this updated ‘Rebate policy’ will provide all staff working for or behalf of NHS Leeds CCG Medicines Commissioning Team a framework and guidance for working with the pharmaceutical or related industries in Primary Care.

RECOMMENDATION:

The Governing Body is asked to:

(a) APPROVE the updated Primary Care Rebate Policy.

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GB 19/139 GOVERNING BODY FORWARD WORK PLAN 2019/20

ITEM MAY JULY SEPT NOV JAN MAR Lead Officer STANDING ITEMS Welcome & apologies X X X X X X Chair Declarations of interest X X X X X X Chair Minutes of previous meeting X X X X X X Chair Matters arising X X X X X X Chair Action log X X X X X X Chair Questions from members of the public X X X X X X Chair Patient Voice X JH PERFORMANCE Chief Officer’s Report X X X X X X TR Integrated Quality & Performance Report X X X X X X HL/KS FINANCE Finance Report X X X X X VPS Approval of Annual Report & Accounts X VPS Approval of Annual Budget X X VPS STRATEGY Strategic Review: X X X X X - CCG Strategy KS - Leeds Health & Care Plan - West Yorkshire & Harrogate STP CCG Operating Plan (incl. high level budgets) X SA/VPS Climate Change SA People & OD Strategy/Refresh X X SA RISK Governing Body Assurance Framework X X X X X X SA Corporate Risk Register X X X X X X SA STATUTORY DUTIES Assurance on delivery of Statutory Duties X Various (TBC) GOVERNANCE Approval of Procurement Plan 2020/21 X VPS Approval of Business Cases/Investments over Various £1.5m (as required) Chair’s Summary of Committee Meetings X X X X X X Committee Chairs Committee Terms of Reference X Committee

Chairs

ITEM MAY JULY SEPT NOV JAN MAR Lead Officer Update to Committee Terms of Reference & Chair Scheme of Reservation & Delegation Committee Annual Reports X Committee

Chairs Governing Body Effectiveness X GS Approval of Governing Body Appointments / Chair Reappointments (as required) Approval of amendments to Constitution (as Chair required) Forward Work Plan X X X X X X Chair Policy Approval (as required) Various Review of Operational Scheme of Delegation X VPS Patient Experience & Complaints Annual Report X JH System Resilience Plan (included in Q&P X PA/HL Summary) EPRR Compliance (included in Q&P Summary) X PA/HL