Council of Members 3 September 2014 Minutes of last meeting: 27 - - PowerPoint PPT Presentation

Council of Members

3 September 2014

Minutes of last meeting:

27 March 2014

• Dr. Richard Proctor, Council of Members Chair

Five Areas to Track Bulletin 4

• Item For Information -
• Dr. Richard Proctor

The Current Situation 1. The NHS Constitution sets a right for patients to be treated within 18 weeks of referral should they require admission. Trusts must ensure that a minimum of 90% of all patients referred are treated within this timeframe. In 2013/14 KCH Denmark Hill failed to achieve the admitted RTT target for the year. 2. As part of the 2014/15 contract the CCG has agreed revised trajectories for RTT performance, which would see the trust achieve the RTT standard from the end of Q2 2014/15. In April, 84.4% of admitted patients were treated within 18 weeks of referral. 3. The over 18 week backlog at the trust is currently at approximately 1,846 (April 2014 figure). The backlog is largest in a number of specialties of which General Surgery, Neurosurgery and Orthopaedics are the main ones. 4. It is important to note that a number of specialties affected by over 18 week waiting times are for services that from 1 April 2013 are commissioned by NHSE England and not the CCG. Actions Taken 1. Acquisition of the PRUH site and development of the Centenary Wing at Denmark Hill has provided further ‘ring-fenced’ elective capacity since October and November respectively. Additional capacity at the Orpington site includes 45 beds and 3 theatres both with phased

• penings with the last theatre opening in January 2014. Centenary Wing development has provided a net additional 16 beds and 1 HpB

theatre which opened in February. These development will increase capacity in Q1 and Q2 2014/15 compared to the same period last year. 2. The trust is focusing on increasing internal capacity and reviewing the funding necessary to continue outsourcing work to the private sector. 3. Providing more information to primary care to support informed choice in relation to waiting times – local CCGs have written to GPs setting

• ut the issues associated with KCH waiting times to ensure GPs are informed of waiting times and able to discussing choice with patients.

On-going Actions 1. From February 2014 there has been an agreed process to transfer Orthopaedic patients from KCH to GSTT. KCH will aim to transfer 30 patients a month until end of Q2, when the process will be reviewed. Following a meeting in June, KCH will also be looking to transfer spinal patients. 2. Maximising internal trust capacity to support the overall decompression of the KCH acute hospital sites and the effective management of available emergency and elective capacity across the trust, to allow for a sustainable pattern of services across each site for the future. 3. King’s consultants undertake regular clinical review of all patients waiting in excess of 18 weeks for treatment.

• 1. Hospital waiting times: 18 weeks for admitted patients

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• 2. IAPT and practice-based counselling

The Current Situation 1. Southwark Psychological Therapies Service (SPTS) is provided by SLaM. Practice-based counselling also provide services in 43

• practices. Both providers deliver talking therapies under the Improving Access to Psychological Therapies (IAPT) national programme.

2. The CCG has a predicted prevalence of 41,929 people in Southwark with depression/anxiety and a target that 15% of these people are seen by IAPT services each year and that 50% of patients ‘move to recovery’ following the intervention. The CCG failed both targets in 2013/14. 3. At present we know there aren’t enough people being seen by all IAPT services (SLaM and counsellors) and not enough of these patients are getting the outcomes they want. 4. We also know there is significant variation in the delivery of counselling services offered across practices in Southwark, which impacts on delivering NICE and IAPT compliant services. 5. Following the CSC decision in December 2013 to re-commission the entire primary care psychological therapies service, a period

• f engagement with stakeholders ended on 31 May. Mental health commissioners have initiated the procurement process for a Southwark

Talking Therapies Service. 6. The tendering process will start on 9 September 2014 with contracts being awarded on 5 January 2015 and the new service commencing

• n 1 April 2015.

Recent Actions Taken 1. Recovery plan to achieve national target by increasing capacity of services using additional staff within main provider. 2. Notice given to providers and information provided about Market Engagement Event on 7 July. 3. HR support to GP practices to clarify the value of TUPE transfers to inform procurement and provide clarity and reassurance to staff involved. 4. Development of procurement documents e.g. Memorandum of Information (MOI), Service Specification. 5. Project Steering Group for procurement identified with meeting dates set. Outcome of Actions / Planned Outcome 1. Effective market testing event on 7 July to guide procurement process. 2. Successful start of the procurement process by end July 2014. 3. Feedback report from engagement period to be reported, currently delayed due to a technical issue with survey.

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• 3. Community clinics and single point of referral

The Current Situation 1. Over the last two years Southwark CCG has been developing pathway specific single points of referral (SPR) and community clinics as part of the CCG’s Programme of Service Redesign. There is a commitment to further expand this community provision in order to shift care out of hospital (as per the aim included in the CCG strategic plans). 2. SPRs are currently operating for MSK (MCATS), Diabetes, Respiratory, and ENT. Community services/clinics exist for MSK, diabetes, dermatology, gynaecology and heart failure (as a step down from secondary care) and a CVD service (AF/hypertension/lipid management). 3. In addition to the SPR & community clinic functions, a number of our community services provide ‘virtual clinics’ to support Primary Care in reviewing practices’ caseloads and providing advice on management. Recent Actions Taken

• 1. Over the last year via virtual clinics, the Diabetes Community Service has supported general practice in their management of patients with

HbA1c and have made a significant contribution - in 2012/13 67.8% of patients on the diabetic register were controlled with HbA1c ≤ 64 mmol/mol and in 2013/14 this increased to 70% (non validated QOF data 13/14).

• 2. May’s PLT was delivered by the ENT Referral & Advice Service, which delivered training targeted at both GPs & nurses. Feedback from

the event was positive and practices have been asked to feedback how they would like to receive additional training and support from the service.

• 3. The CCG recently reviewed Southwark’s patient referral services (PRS); however findings were inconclusive. National evidence suggests

that models which build on peer review and learning have maximum clinical and cost effectiveness. Therefore, the next stage will be for the CCG to work with localities in exploring a potential model of PRS embedded in neighbourhoods. This will consider the value of condition specific versus system wide approaches. Outcome of Actions / Planned Outcome 1. The delivery and uptake of the local SPRs by all Southwark practices is vital to reduce activity and deliver Southwark’s acute QIPP plans and we ask for practices to ensure appropriate utilisation is increased. 2. Future engagement events are currently being scheduled to design future service models for neighbourhood networks of care and community hubs. This will support the future development of community clinics. 3. The development of community hubs will provide Southwark residents with services closer to home with reduced waiting times.

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• 4. Communication between district nursing and primary care

The Current Situation 1. During 2012/13 the CCG’s contract with Guy’s & St. Thomas’ Community Health Services (GSTCHS) included a CQuIN (contractual standard) focused on implementing monthly meetings between GP practices and local district nurses in Southwark and Lambeth. 2. GSTCHS failed the 75% target in quarter 4 last year (Jan-March 2013), however nearly 70% of GP practices were having regular monthly meetings by the end of the year across the 2 boroughs. In the main, performance was worst in the south of the borough. GSTCHS attributed this due to poor data recording. 3. 2013/14 performance reported for quarter 4 2013/14 (Jan - Mar) shows that 62.4% of meetings were taking place between GP practices and district nurses. (Q1 – 46.8%, Q2 – 50.4%, Q3 - 56.7%). The equivalent figure in Lambeth was 81.3%. The service reports exceptions (e.g. cancel meetings). Recent Actions Taken 1. A action plan has been shared with commissioners and progress is monitored at fortnightly meetings between Southwark & Lambeth CCGs and the head & deputy head of district nursing. A report was presented at the GST CQRG meeting in November with an update in February 2014. 2. Service reports on-going difficulties in recruiting qualified District Nurses and has been undertaking a national recruitment programme during Q4 which has attracted little interest. This is a national issue and so international recruitment will take place during early 14/15. 3. Community matron service was integrated with the district nursing team to ensure core service delivery during winter pressures. Outcome of Actions / Planned Outcome 1. 2014/15 District Nurse Service Improvement plan is part of 2014/15 GST integrated contract. 2. CCG will continue to monitor recording of meetings and progress. 3. To work with partners to design integrated nursing approach in line with neighbourhood working arrangements currently in development. 4. Discussion taking place to develop outcome quality indicators for the service. Potential indicators include; wound management, HBa1C reduction and continence management.

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• 5. Southwark & Lambeth Integrated Care (SLIC) programme

The Current Situation 1. The SLIC frail elderly pathway has shown slippage against trajectories for @Home activity increases and take up of the primary care pathway for health assessments and case management. A full briefing on the SLIC Older People’s pathway will be available July 2014. 2. The proposed Long Term Conditions workstream has now broadened into a ‘Resilience’ workstream looking at supporting care planning, self management and care co-ordination. A review of ‘what works’ is being conducted, leading to a business case and potential GST Charity Bid. 3. The System Enablers workstream, looking at how to support wider system integration, is focussing on three main strands of work; commissioning framework, financial incentives and the provider model for integration. 4. Other planned work includes work on the discharge pathway and work on nursing homes, falls and dementia. Work on enablers including information sharing and workforce development is progressing, but at a relatively slow pace. 5. Southwark’s Better Care Fund includes a number of schemes which support our integrated care plans, including self management and seven day working, as well as pick up of the admission avoidance programme from April 2015. Recent Actions Taken 1. Agreement of a contractual specification and trajectory for the @Home service with GST. This will be reviewed at regular stocktake meetings, and CCGs will also have operational meetings with trusts to ensure that the interface between hospital and the admission avoidance pathway is as smooth as possible. 2. The CCG has contracted with neighbourhood groups for delivery of the elderly pathway in primary care, with the expectation that working together will help all practices to increase the level of delivery, through for example joint employment of Integrated Case

• Managers. Activity will be increased across the borough from April as a result of the neighbourhood delivery of extended services.

3. The SLIC Sponsor Board has given approval to a direction of travel for the System Enablers work including the agreement to pool commissioning budgets to support a move towards outcome based commissioning and the use of capitated budgets to support more integrated care. 4. The CCG is in discussion with the Council about a programme for developing the Better Care Fund plans which compliment the SLIC programme. Outcome of Actions / Planned Outcome 1. Increased utilisation of @Home beds over the period to September. 2. Increased delivery of HHAs and Case Management; noting risk on this with delay to mobilisation of neighbourhood working. 3. Agreement on development of shadow budgets and new contracting frameworks expected July - September.

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CCG Financial Position Month 4, 2014/15

Malcolm Hines, Chief Financial Officer

Financial Performance Duties

Duty YTD Target YTD Performance RAG Annual Target Forecast Performance RAG Achieve planned surplus (Expenditure not to exceed income) £1,991k £2,043k £5,972k £6,072k Capital resource does not exceed the allowance N/A N/A N/A N/A Revenue resource does not exceed the allowance £120,423k £118,380k £374,424k £368,352k Capital Resource use on specified matters does not exceed the allowance N/A N/A N/A N/A Revenue resource use on specified matters does not exceed the allowance £118,131k £116,141k £367,209k £361,237k Revenue administration resource use does not exceed the allowance £2,292k £2,239k £7,215k £7,115k

• The above duties correspond to those reported in Note 42 of the Annual accounts, and represent

the statutory duties of the CCG.

• To support the delivery of the above, an in-year QIPP programme of £15,591k has been
• established. QIPP monitoring information is included on page 17.

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Summary of Position

• Southwark CCG was underspent at the end of Month 4 at £2,043k, for the year to date.
• This is marginally above the planned pro rata effect of £1,991k, and the CCG is on track to

achieve the annual target surplus of £5,972k .

• The CCG has utilised £638k of reserves to achieve this year-to-date (YTD) position. This is

mainly to cover adverse variances in the YTD reported position for Acute.

• In the likely forecast position, £2.7m of the £14.7m reserves has been utilised to achieve our

target position. Additionally, £1,500k is set aside for a potential national Continuing Care risk pool, and £1,050k for adjustments between CCGs regarding the Market Forces Factor pertaining to King’s and the PRU having merged into one Trust, which affects national acute tariff prices. This leaves £9.5m of reserves currently uncommitted in the likely forecast position.

• In the worst case projection, we would need to utilise more reserves (£8.3m). This would still

enable the CCG to meet its financial targets and would result in a lower uncommitted reserves figure of £3.9m.

• The CCG is currently forecasting successful achievement of the £15.59m QIPP programme. Any

slippage occurring in future months will be covered by the application of reserves.

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CCG Programme Budget Summary 2014/15 - Month 4

Programme Budget Annual Budget (£k) Variance to Month 4 (£k) Predicted End of Year (£k) Best Case (£k) Worst Case (£k) Acute 204,330

• 610
• 1,828
• 10
• 5,836

Client Groups 71,248

• 66
• 1,000
• 765
• 2,000

Community and Primary Health Services 33,549 38 100 200 Prescribing 31,200 425

• 426

Corporate Costs 6,181 150 Earmarked Budgets and Reserves 14,729 638 2,728 8,262 Planned Surplus 5,972 1,991 5,972 5,972 5,972 Total

367,209 1,991 5,972 5,972 5,972

Reserves not utilised in above position (netted off for Continuing Care and MFF) 9,451 12,179 3,917 Reserves not yet utilised in above position (Month 3 for comparison) 10,048 12,627 3,362

Note: a red negative sign indicates budget overspend

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CCG Running Costs Summary 2014/15 - Month 4

Running Costs Annual Budget (£k) Variance to Month 4 (£k) Predicted End

• f Year (£k)

Best case (£k) Worst Case (£k) Running costs 7,215 53 100 150 Month 3 (for comparison) 7,215 56 100 150

• The running costs allocation is separate from the Programme budget and should be monitored

separately.

• The reason for the underspend at Month 4 relates to discretionary non-pay expenditure.

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QIPP Monitoring

Annual Plan Year to Date Forecast SOUTHWARK CCG QIPP 2014-15 QIPP Target 2014-15 (Post-RAG-Rating) (£k) YTD Plan (£k) YTD Actual (£k) YTD Variance (£k) YTD RAG Outturn (£k) Variance (£k) Acute/Community 10,000 3,333 3,313

• 20

10,000 Mental Health 2,500 833 833

2,500 Primary Care Prescribing 2,241 747 747 2,241 Community Services 500 167 167 500 Continuing Care 250 83 83

250 Corporate 100 33 33

100 Southwark CCG QIPP Target 2014/15 15,591 5,197 5,176

• 21

15,591 Ytd Shortfall from plan:

• 0.4%

Forecast shortfall from plan: 0.0%

• Total QIPP savings plans of £16,388k are in place for 2014/15. However, in order to achieve the

plans, an investment of £797k has been made. This includes £455k on Mental Health QIPP schemes and £342k on Acute schemes . This leaves the net QIPP value at £15,591k.

• The CCG is forecasting to deliver the QIPP programme in full in 2014/15.

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Financial Risks & Mitigations

• The value of the potential risks reported on the previous page is in addition to the forecast outturn
• position. The purpose of this table is to report on risks and mitigations that are not included in the

forecast – i.e. to illustrate anything that puts the reported forecast outturn at risk.

• The best case impact is £2.79m: no risks materialise and funds remain uncommitted.
• The worst case impact is £0.29m: all risks occur, further actions are unsuccessful and

uncommitted funds all used to mitigate risks.

• Contract Reserves reported in the “Mitigations” table (page 18) exclude £7.16m which represents

the 2% non-recurrent headroom budget. This is reported within “Non-Recurrent Expenditure” in the Earmarked Budgets & Reserves 2014/15 table (page 15) and therefore results in a difference between the two reserves figures reported. The headroom budget is not available to be used to mitigate risks, although it is held within reserves.

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Proposed Changes to the CCG Constitution

• Dr. Richard Proctor and Malcolm Hines

• Health & Social Care Act 2012 requires any CCG Constitution change to

be agreed with NHS England.

• NHS England must be satisfied that:

– Changes comply with the legislation, – Agreement of proposed changes has taken place with member practices, – Changes have been formally signed off at a Governing Body meeting.

• Since our CCG Constitution was created in September 2012, a set of

changes was approved by NHS England in January 2014.

Introduction: Proposed Constitution Changes

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1. Foreword Insert updated foreword from the new Chair of the Governing Body. 2. Collaborative Framework/Joint Arrangements To insert, “The CCG is able to enter into joint commissioning arrangements with other NHS or non-NHS bodies.” 3. Council of Members quorum At present the document refers to 24 practice representatives. Proposal to update this and change to: “The quorum for Council of Members will be a simple majority of practices (Practice Representatives or Deputy Practice Representatives)”.

Proposed Constitution Changes (1)

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4. Governing Body representation

To insert, “Governing Body Clinical Leads will be a maximum of one per practice to ensure Conflict of Interest can be managed effectively”.

• 5. Lay Member role and appointment process

To insert, “Lay Members will be appointed for a period of 2 years with a further extension of 2 years permissible with the agreement of Remuneration Committee. Lay Members will be appointed by the Governing Body”.

Proposed Constitution Changes (2)

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6. Conflict of Interest Policy To refresh the Conflict of Interest Policy to include new COI Panel processes approved by the Integrated Governance and Performance Committee. 7. Audit Committee attendance To insert; “Council of Members representatives will attend the March and May Audit Committees where the draft and audited Final Accounts and Annual Reports are approved”. 8. Procurement Strategy To be refreshed in line with current national procurement guidance.

Proposed Constitution Changes (3)

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Acute Performance and the Impact on Southwark Patients

Dr Jonty Heaversedge, CCG Chair and Andrew Bland, CCG Chief Officer

Summary: A&E 4 Hour Standard

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A&E waits all types (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission

Q1 Q2 Q3 Q4 2014/15 Apr May Jun Q1 KCH (Trust wide) 89.4 87.5 87.4 89.4 89.9 89.0 KCH (Den Hill) 96.3 95.0 94.2 93.1 92.0 93.3 93.1 92.9 GSTT 95.9 95.7 96.8 96.7 97.1 97.0 96.4 96.8 King’s (Denmark Hill) failed the last three quarters. GSTT have met the performance standard in all four quarters of 2013/14 and in Quarter 1 2014/15. Main causes:

• Growth and fluctuations in demand,
• Increased acuity of patients
• Bed pressures resulting in poor outflow from emergency department
• Sub-optimal pathways for patients with mental health needs
• Repatriation delays
• Discharges.

Summary: 18 week waits

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King’s (Denmark Hill) failed to meet this standard in all of the last 12 months. This is the main contributory factor to extended waits for more Southwark patients. King’s currently have a backlog of 1,700 patients who have waited for more than 18 weeks for admission and remain on waiting lists. GSTT have met the performance standard in every month of the last year. Main causes:

• Bed pressures from emergency activity
• Capacity pressures at the Denmark Hills site
• Sub-optimal pathways for patients with mental health needs
• Repatriation and discharge delays

RTT admitted (target 90%) - The percentage of admitted pathways completed within 18 weeks

Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Apr May Jun SCCG 89.3 88.4 87.3 86.0 87.3 89.0 88.2 84.1 81.5 84.4 84.4 82.3 KCH (DH) 88.1 87.1 88.6 87.7 88.7 89.0 87.8 83.6 81.7 84.5 83.3 80.6 GSTT 92.6 93.1 90.9 90.9 90.6 93.4 91.0 91.7 90.8 91.9 91.0 90.7

Summary: Long waiters

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King’s (Denmark Hill) failed to meet this standard in all of the last 12 months. The number of long waiters has grown significantly over this period of time. Long waiting patients at King’s make up 25% of all long- waiters in England. A significant number of Southwark patients have waited for more than one year and remain on waiting lists. GSTT have met the performance standard in 10 of the 12 months last year. Main causes:

• Demand on beds from emergency pressure
• Capacity constraint at the Denmark Hills site
• Lack of suitable options for out-sourcing long-waiting patients

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Apr May Jun Southwark CCG 7 3 8 8 10 6 14 14 18 13 20 15 13 KCH (Trust wide) 31 24 28 29 33 27 78 79 109 95 123 104 107 GSTT (Trust wide) 1 2

Long wait standard (zero tolerance) - The number of patients waiting 52 week+ for treatment

The impact of acute care pressures on patients

• Patients’ experience of care diminishes
• Increased emergency admissions and restricted capacity means an increased proportion of

elective patients are waiting over 18 weeks for the conclusion of their treatment. Other patients are also waiting longer than they otherwise would.

• More elective patients have their operation cancelled with late notice. At King’s the rate of this is

almost twice what it is at Guy’s and St. Thomas’.

• Patients wait longer in A&E department due to lack of available beds in hospital wards

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What is King’s doing to address these pressures?

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1. Development and agreement of System Resilience Plans, which cover both elective and non-elective across Lambeth, Southwark and Bromley. 2. Internal capacity reviewed to maximise internal trust capacity across Denmark Hill, PRUH and Orpington sites, to support the overall ‘decompression’ of the KCH acute hospital sites and the effective management of available emergency and elective capacity across the trust. Plans are in place to release capacity at the Denmark Hill site throughout the year, with several service moves taking place in the next two months. 3. Trust implementing additional national RTT initiative funded by NHS England from July to September to further clear backlog of 18 week plus waits. 4. Long waiting patients under regular clinical review and arrangements have been made to outsource to private sector for those waiting for elective neurology and bariatric. Ring-fenced beds have been identified in other specialties to prioritize long waiters and others 18 week plus waits have been transferred to GSTT (orthopedics). 5. Representatives of the CCGs and KCH meeting with Lewisham and Greenwich NHS Trust to discuss repatriation protocols.

What is the CCG doing to address these pressures?

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1. Extended Primary Care access

• Service specification to be signed off at August with providers then developing detailed pathways
• Service mobilisation with first site launching on 1st October
• Contractual discussions initiated and assurance process for mobilisation agreed.

2. CCG working with practices to inform local referrers of likely waiting times for patients at King’s; support review of access; and promote use of alternative urgent care services (e.g. rapid response and @home). 3. Performance management of the trust and application of appropriate contractual penalties. 4. Audit of mental health presentations completed and action plan to be developed by working group in September. 5. Southwark & Lambeth Integrated Care (SLiC) Simplified Discharge Workstream programme to develop options appraisal for unified point of access to be developed for agreement in September. 6. Revision of service specification for King’s urgent care service and confirmation of procurement route in September. Additional service specification to be developed for 111 incorporating learning from other areas in England.

Question and Answers

Co-commissioning of Primary Care

Andrew Bland and Dr Richard Proctor

Background

• In May 2014 NHS England invited expressions of interest from CCGs in exploring co-

commissioning

• Following discussions with CCGs in south east London and the LMC an expression of

interest was submitted by the six Governing Bodies in June 2014 committing to further exploration and stating a series of conditions: – That the CCG wanted sufficient opportunity to engage its members – There was no interest in the holding of contracts or performance managing them – That further exploration would need to be informed by a greater understanding of what co-commissioning would look like.

• We began a local discussion with members to gather initial views in June and we are

now at a stage where we would like to consider and develop what co-commissioning could look like in Southwark and understand the benefits it would hold for our patients.

• We wish to enhance our engagement now in order to do that…

What is primary care co-commissioning?

• Co-commissioning of primary care services provides CCGs greater control
• ver how those services are commissioned for our population.
• It does not remove the statutory responsibility of NHS England for

commissioning these services – CCGs become co-commissioners.

• It is predominantly focused upon primary medical services (community

pharmacy, dentistry and optometry remain with NHS England commissioners).

• It is flexible – emerging policy proposals define a maximum scope of

responsibility and describe options around the level of responsibility CCGs would wish to take.

• Crucially it is changing … national policy is not yet finalised.

Context - Place Based Commissioning

The proposals for co-commissioning of primary care services sit within a wider strategic direction that seeks to align the decision making of all commissioners around local populations.

“If we want to better integrate care outside hospitals, and properly resource primary, community and mental health services – at a time when overall funding is inevitably constrained – we need to make it easier for patients, local communities and local clinicians to exercise more clout over how services are developed… “That means giving local CCGs greater influence over the way NHS funding is being invested for their local populations. As well as new models for primary care, we will be taking a hard look at how CCGs can have more impact on NHS England’s specialised commissioning activities.”

Simon Stevens, NHS England Chief Executive, June 2014)

Why change?

• Current commissioning of services is fragmented, undertaken in many places

and at varying degrees of scale.

• For primary care this currently operates as a ‘Single Operating Model’ or SOM

for England that often neglects local concerns, needs and differences.

• Commissioning intentions and indeed investment decisions have the potential

to (and in some cases have been) contradictory.

• Greater local control over strategic direction, prioritisation, decision making

and the ability to join up enabling strategies (such as estates or IT) and incentives.

• Co-commissioning does not make the NHS financial ‘pot’ any bigger BUT it

has the potential to facilitate shifts of resources between care settings or protect primary care funding once budgets are set.

Context – The ‘pot’ is getting smaller

For CCGs - the challenge for south east London is a cumulative savings of £308m between 2014 - 2019. For Primary Care - the new allocation policy agreed in December 2013 results in London being over target by 2.8% and receiving a base level of funding increase in 2014/15 of 1.60% against a national average of 2.14%. This further impacts in 15/16 with a resource increase of 1.29%. For Specialised services - these services face a reduction of approximately 6-7% in 2014-15, and more in later years. For adult social care - many Local Authorities face unprecedented pressures on their resources and in some instances are looking to save over 30% of their current expenditure over the next 3-4 years.

Net QIPP savings, 000s 2014/ 15 2015/ 16 2016/ 17 2017/ 18 2018/ 19 TOT Bexley 14,694 8,418 5,193 5,762 5,757 38,824 Bromley 12,012 12,140 7,900 5,400 5,400 42,852 Greenwich 8,600 7,300 4,300 6,000 6,000 32,200 Lambeth 15,319 20,233 17,832 14,645 13,081 81,110 Lewisham 9,990 13,119 11,546 9,597 9,833 54,085 Southwark 15,591 13,219 10,710 9,007 9,327 57,854 SEL Total 76,206 74,429 57,481 50,411 49,398 307,924

Rebalancing spend if the answer?

What is the potential scope?

National policy indicates a wide spectrum of potential activity:

• Working with patients and the public and with Health and Wellbeing Boards to

assess need and decide strategic priorities.

• Designing and negotiating local contracts (e.g. PMS, APMS, any enhanced

services commissioned by NHS England).

• Approving ‘discretionary’ payments, e.g. for premises reimbursements.
• Managing financial resources and ensuring that expenditure does not exceed

the resources available.

• Monitoring contractual performance and applying any contractual sanctions.
• Deciding in what circumstances to bring in new providers and managing

associated procurements and making decisions on practices mergers. Importantly – this is for CCGs to determine

What are the levels of involvement?

National policy indicates a choice of potential forms:

• A. Influence – greater CCG involvement in influencing commissioning decisions

made by NHS England.

• B. Joint commissioning arrangements – whereby CCGs and NHS England

make decisions together, potentially supported by pooled or aligned funding arrangements.

• C. Delegated commissioning arrangements – whereby CCGs carry out

defined functions on behalf of NHS England and are held to account for how effectively they carry out these functions by NHS England. Again and importantly – this is for CCGs to determine

What has been the thinking to date?

CCGs in south east London have made an expression of interest as Governing Bodies to explore co-commissioning further. Emerging thinking suggests:

• A. Influence – Some support, however we have the opportunity to influence now

and that opportunity has not secured local responses of being effective.

• B. Joint commissioning arrangements – Most interest, governance that allows

a greater degree of control provided the scope is appropriate

• C. Delegated commissioning arrangements – Little or no support, CCGs would

not wish to hold or performance manage general practice contracts. Importantly – this is for CCGs to determine

Getting the right scope….

Emerging thinking suggests: Greater support for Commissioning

• A scope that allows CCGs to work with NHS England and take joint and

binding decisions upon primary care commissioning intentions and investment that is locally relevant and addresses the needs of our population.

• This may allow joint policies / joined up thinking on estates, localising incentive

systems and IT or training / workforce planning may also be attractive.

• Ability to lock in primary care budgets locally and shift resources within the
• verall ‘pot’ may facilitate overall objectives of primary and community care.

Little or no support for contracting or performance management

• These functions would be held by NHS England. CCGs would not

performance manage or determine contractual action on peers.

What are others Saying?

Nationally and across London there appears to be appetite for co- commissioning if the approach is ‘right’ Commissioning Form England London A – Influence 19 3 B – Joint 103 27 C – Full delegation 74 2 But there are a number of unknown areas of policy and ‘hot topics’:

• Managing Conflicts of Interest
• Governing Joint decision making
• Financial allocations in future
• Levels of prescription in approach
• Commissioning resources to undertake these roles

Where are we now?

• The CCG has been keen to engage the membership from day one (accepting

that policy is emerging).

• Having started discussions virtually we want more face to face engagement -

Views will be fed in to a proposition document in September.

• We will then engage on that proposition from October and further develop it for

a final consideration towards the end of this year.

• We would like to understand and develop our own views as policy emerges…

this will leave us best placed to influence and respond (We know that later this month or next more definitive policy will emerge).

• Where there are choices we want to make the most of them, where there

are not we would want to ensure the best possible deal for our population.

Table discussions

What would you like to know more about? Who and how should we engage with stakeholders on this? What do you see as the greatest opportunities here? What are your concerns?

Join the discussion at: http://www.southwarkccg.nhs.uk/members- zone/commissioning/Proposals/co-commissioning-primary-care

Feedback from table discussions

Question and Answers of the CCG Governing Body

• Dr. Richard Proctor

Any Other Business

• Dr. Richard Proctor